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Abstract

Food allergy has been recognised by the World Health Organisation as a chronic disease that could lead to fatality. The symptoms can mediate from mild to severe consequences. Some cases have reported that food allergy sufferers are bullied and are discriminated at workplace, thus increasing their stress level, apart from facing difficulty in consuming certain food due to allergy. This has an adverse effect on the quality of life amongst food allergy sufferers. Medical bills are increased when food allergy sufferers become unknowingly exposed to food allergen. Hence, this study investigated food allergens among food allergy sufferers in order to make their lives better. A total of 250 respondents participated in an online survey. Surprisingly, apart from chicken, soybean and other food allergens that have been listed under the Big Eight Allergens, the respondents mentioned some fruits that could trigger allergic reactions, such as rambutans and watermelons. Food allergy sufferers can be allergic to seafood and seafood products as well, such as shrimp paste or locally known as belacan, which refers to fermented shrimp paste cured under the sun. It is a common food ingredient used among Malaysians. The study findings offer practical insights, such as avoidance of food allergens amidst food allergy sufferers and help the government to carefully manage for menu planning. The knowledge contribution of this study reveals several specific food and fruits, as aforementioned, which appear to be common and nutritious food, yet harmful to food allergy sufferers.
Article
Revelation of Children and Adult’s Food Allergen in
Malaysia
Norrina Din1, Basri Rashid2, Kamal Izzuwan Ramli3, Nur Aliah Mansor4 and Dahlan Abdullah5
1,5Faculty of Hotel and Tourism Management, UniversitiTeknologi MARA Penang Branch;
norrina.din@uitmppinang.edu.my,dahla707@ppinang.uitm.edu.my.
2,3 School of Tourism, Hospitality and Event Management, College of Law, Government and International
Studies, Universiti Utara Malaysia; basri@uum.edu.my,izzuwan@uum.edu.my
4Faculty of Hospitality, Tourism and Wellness, Universiti Malaysia Kelantan; aliah.m@umk.edu.my
* Correspondence: norrina.din@uitmppinang.edu.my: Tel +6043823677
ʈ These authors contributed equally to this work
Abstract: Food allergy has been recognised by the World Health Organisation as a chronic disease
that could lead to fatality. The symptoms can mediate from mild to severe consequences. Some
cases have reported that food allergy sufferers are bullied and are discriminated at workplace, thus
increasing their stress level, apart from facing difficulty in consuming certain food due to allergy.
This has an adverse effect on the quality of life amongst food allergy sufferers. Medical bills are
increased when food allergy sufferers become unknowingly exposed to food allergen. Hence, this
study investigated food allergens among food allergy sufferers in order to make their lives better.
A total of 250 respondents participated in an online survey. Surprisingly, apart from chicken,
soybean and other food allergens that have been listed under the Big Eight Allergens, the
respondents mentioned some fruits that could trigger allergic reactions, such as rambutans and
watermelons. Food allergy sufferers can be allergic to seafood and seafood products as well, such
as shrimp paste or locally known as belacan, which refers to fermented shrimp paste cured under
the sun. It is a common food ingredient used among Malaysians. The study findings offer practical
insights, such as avoidance of food allergens amidst food allergy sufferers and help the
government to carefully manage for menu planning. The knowledge contribution of this study
reveals several specific food and fruits, as aforementioned, which appear to be common and
nutritious food, yet harmful to food allergy sufferers.
Keywords: food allergy, food allergen, fruits, seafood, nut and milk
1. Introduction
Food allergy refers to the opposing reaction to food allergen. Food allergy reactions can be mild,
severe, or even lead to fatal consequences [1], hence an important area of study. This is the reason on
why food allergy has been listed by the World Health Organisation as a chronic disease [2]. Despite
the chronic nature of this disease, people tend to ignore the severity of food allergy due to limited
knowledge pertaining to food allergy [3,4]. Awareness seems to be given more focus on
cardiovascular diseases and cancer, while omitting food allergy [2]. Interestingly, more people are
affected by food allergy than the mentioned diseases being given focus.
The prevalence of food allergy among people worldwide cannot be denied. The number of
global population affected by food allergy had been estimated to be 220-250 million people [2]. In
Europe, the number stood at 11-26 million, while in Malaysia, the percentage escalated up to 10-15%
amongst the children population [2]. Some 877 severe food allergy sufferers were reported in
Norway and this population has kept increasing [5]. The United States reported a 10% increase in
food allergy population [6], while in the United Kingdom, 1-2% of adults were affected by food
allergy and 5-8% amidst the children population [7]. In Taiwan, about 2,108 people out of 30,018
were estimated to be food allergy sufferers [8]. To date in Japan, about 45,807 children were affected
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© 2019 by the author(s). Distributed under a Creative Commons CC BY license.
by food allergy and 3,499 experienced food allergy reactions [4]. As aforementioned, the population
of food allergy sufferers seems to be increasing in many parts of the world.
Food allergy can affect many people at any stage in their lives. It could be anywhere between
infancy and adulthood [9]. Food restriction is one of the many methods to avoid food allergy by
sufferers from allergic reactions [10]. Some symptoms of food allergy include swelling in the face
regions (e.g. lips, tongue, and throat), difficulty in breathing, stomach cramps, diarrhoea, and
vomiting [2]. The symptoms of food allergic reactions appear immediately and the victims are
bound to suffer from food allergy [11]. All the symptoms tend to increase the level of anxiety,
absenteeism from work or school by parents and food-allergic children [12], bully [13], and face
discrimination at workplace [14]. All these consequences incur medical costs and can lead to low
quality of life [15].
More than 170 food allergens have been identified [16]. In the Asia Pacific, foods that are
known to cause allergies that should be avoided are shellfish because they could trigger
anaphylactic shock that may be fatal. Shellfish has been identified as the top ranking food allergen
[17]. Food allergens classified in the Big Eight Allergens are eggs, cow’s milk, fish, shellfish, peanuts,
tree nuts, wheat, soya [18], sesame seeds [16], birds nest [19,21], cheese, beef, chocolate [20], ham,
duck, chicken, and some fruits [21], namely rambutans, banana, watermelons, apples, oranges,
kiwis, and strawberries [22]. Besides fruits, one of the most common ingredients used in Malaysian
cooking, which is ‘belacan’ or shrimp paste, a seafood product [23], appears to be a type of food
allergen as well.
The three major ethnic groups in Malaysia are Malays, Chinese, and Indians, along with other
minor ethnic groups. These ethnic groups differ in various respects, namely food habits, practices,
and food restrictions [24]. Previous studies have identified that food allergens among the Malaysian
population include crab, prawn, squid, cockle, mackerel, anchovy, milk, egg, soy, wheat, rice [25],
mutton, beef, chicken, and banana [26]. The skin prick test verified that rice and shrimp were found
to cause allergic reactions amongst food allergy sufferers. This study was conducted to further
investigate the food allergens among food allergy sufferers, both adults and children which is not
previously integrated examined by other researchers.
2. Methods
An online survey was distributed to the respondents who worked in the nursery. Out of 600 of
the total population, only 250 responded. The sample population were nursery employees. The
reason for choosing the sample was because more working women in the workforce require them to
send their children to care centres for early education. Children are easily affected by food allergies,
thus demand special attention. Consent was obtained from the nursery authorities. A pilot study
was conducted among 30 respondents, which were excluded from the sample size. Open-ended
questions were embedded to gather information pertaining to food allergens for both groups -
nursery adult employees and children at the nursery. The Malay language was used in the survey as
it is the national language and officially used in Malaysia. The survey was divided into several parts;
Part A dealt with the demographic profile, and Part B was about food that they were allergic to.
Open-ended questions were included to gain information about food allergies from the respondents.
The results were analysed descriptively using Statistical Analysis for Social Science (SPSS) version 22
software program. The study outcomes are tabulated in Tables 1, 2, and 3.
3. Results and Discussion
The respondents were females, similar to the study conducted by [27], which investigated the
management of food allergy among nannies. Turning to this study, the respondents were confined
to the Malays. The summary of the demographic profile is depicted in Table 1.
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Table 1. Summary of the Demographic profile (n=250)
Demographic Profile
Frequency (%)
Gender
Female
250 (100)
Race
Malay
250 (100)
Age
18-25
23(9.2)
26-35
36-45
46-55
55 and above
93(37.2)
58(23.2)
62(24.8)
14(5.6)
Working experience
6 months and below
1-2 years
3-4 years
5 years and above
28 (11.2)
18 (7.2)
18 (7.2)
186 (74.4)
3.1 Food allergens among children
The most significant information retrieved in this study is food allergen. The abundance of food
makes food allergy sufferers, who are mainly children and their parents, to carefully check and
select suitable food prior to consumption. The respondents (nursery employees) were required to
report the food allergens of their students and the results are given in Table 2. 20.8% of the
respondents reported that the food allergy sufferers were allergic to seafood [28], such as prawn,
squid, crab, cockles, and oyster [29]. In Malawi and in Malaysia, seafood seems to be the major
contributor that can trigger allergic reactions among food allergy sufferers [26,29]. Another 12% of
the respondents reported that the food allergy sufferers were allergic to nuts. Nuts are identified as a
higher contribution for the food allergy reaction in the United Kingdom [30].
A total of 8.8% of the respondents reported that the food allergy sufferers were allergic to
seafood and nuts, while 2% of the respondents said that the food allergy sufferers were allergic to
multiple food allergens, such as seafood, nuts, eggs, and fruits. Another 1% of the respondents
informed that the food allergy sufferers were allergic to chicken, meat, and 1% of them also reported
to have multiple food allergens like meat and milk, nut and eggs, nut and meat, seafood and egg,
seafood, nut and egg, seafood, nut and fruits. Meanwhile 1% reported that the have the combination
of food allergens such as seafood, chicken, egg and meat. Nonetheless, only 0.8% of the respondents
informed that the food allergens of their students were eggs, seafood, milk, chicken, and soybean,
similar with previous studies [26]. Additionally, fruits, such as watermelons and rambutans, were
reported to cause allergies in this study, which appear to be in line with prior studies [26,30]. The
minority of the food allergy sufferers were allergic to meat, milk, nuts, eggs, seafood, and chicken, as
reported by 0.4% of the respondents. This included ingredients, such as milk, which are used in
making other foods (e.g. cakes, butter, and cheese) [27]. The results revealed that the food allergy
sufferers were allergic not only to the one food allergen, but also to multiple food allergens [3]. This
means; extra precaution must be taken to avoid such food and the ingredients that go into other food
types as well [29].
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Table 2 Food allergens among children (n=250)
Food allergen
Frequency (%)
Chicken
3 (1.2)
Egg
2 (0.8)
Meat
1(0.4)
Meat and milk
1(0.4)
Nut
30 (12)
Nut & egg
1(0.4)
Nut & meat
1(0.4)
Nut & milk
3 (1.2)
Seafood
52 (20.8)
Seafood & chicken
2(0.8)
Seafood & egg
3 (1.2)
Seafood & meat
1(0.4)
Seafood & milk
2 (0.8)
Seafood & nut
22 (8.8)
Seafood, nut & egg
4 (1.6)
Seafood, nut & fruits
4 (1.6)
Seafood, chicken, egg &
meat
1(0.4)
Soybean
2(0.8)
Watermelon &Rambutan
2(0.8)
Total
250
3.2 Food allergen among adults
Nursery employees were required to report on the food that they were allergic to as well. As a
result, 86.6% of the respondents claimed that they had no food allergy, whereas 10% of them were
allergic to seafood and seafood products, such as prawns, squid, crab, cockles and anchovies
[26,29,31]. The respondents were not only allergic to seafood, but also to the by-products of seafood,
such as shrimp paste (belacan), cencalok, and fermented anchovies (budu). Belacan’ or shrimp paste is
a common food ingredient consumed daily in the Northern part of Malaysia, while cencalok’ and
budu’ are usually consumed in the East Coast of Malaysia. ‘Belacan’ is usually used to make chili
gravy or ‘sambal’, a thick curry paste to be served with popular dishes of Malaysia, namely Nasi
Lemak. The condiments for Nasi Lemak, such as peanuts and anchovies, are also classified under the
Big Eight Allergen food group. Only 2% of the respondents reported that they were allergic to nuts.
A very small percentage, 0.4% of the respondents, reported to be allergic to chicken, seafood, and
nuts. All information pertaining to the nursery employees is summarised in Table 3. The results
from this survey signify that most of the food allergy sufferers are allergic to similar food reported
from across the globe [29].
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Table 3 Food allergen among adults (n=250)
Food allergen
Frequency
(%)
217 (86.6)
1 (0.4)
5 (2.0)
25 (10.0)
1 (0.4)
1(0.4)
250
4. Conclusions
In conclusion, it is important to investigate food allergies among food allergy sufferers. This
helps sufferers to identify and to avoid foods that trigger allergic reactions. Hence, they will not
suffer allergic reactions, simply by eliminating the source. Another significant aspect refers to the
hidden ingredients used in cooking and served together with certain food, which may cause food
allergies. Hence, awareness on the ingredients is integral in eliminating food allergies among food
allergy sufferers. Once they are aware of the ingredients used, they can ask and check prior to
consumption, particularly the ‘hidden’ ingredients. In addition, studies related to food allergies are
in scarcity. Food allergy sufferers face extreme challenges because they are exposed to risks that may
even jeopardise their lives. Public awareness on food allergy is considered minor, as they
underestimate the impact of it upon food allergy sufferers, unless and until they experience the
seriousness of this disease. Wrongly taken, a morsel of ingestion, cross-contact or direct contact with
the food allergen can trigger the allergic reaction, and even fatality. The impact of food allergic
reactions increases stress level, rate of absenteeism, and medical costs, while deteriorating quality of
life. Investigation of food allergens among adults and children in Malaysia ought to help the
government to carefully choose the ingredients for menu planning, especially at nurseries and
schools. Finally, investigations on managing and looking into the needs of food allergy sufferers
must be further explored.
Author Contributions: N.D; writingoriginal draft preparation, conceptualization, and methodology, D.A,
validation, N.M; writingreview and editing, B.R and K.I.R; supervision,.
Funding: “This research received no external funding”
Acknowledgments: I would like to express my deepest appreciation to all those who provided me the
possibility to complete this research.
Conflicts of Interest: “The authors declare no conflict of interest.”
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There remains a paucity of research in food allergies in Sub-saharan Africa. It is the aim of this study to determine the self-reported prevalence of food allergies and consumers’ perceptions towards food allergen labelling in Mauritius. A survey was conducted in four supermarkets in the Municipalities of Vacoas-Phoenix, Quatre-Bornes and Moka during the period of September to November 2017. The questionnaire was designed based on previous studies and administered using a face-to-face interview approach to increase completion rate. Descriptive analysis and one-way ANOVA between subjects design were conducted. Shellfish was reported as the most common causative agent followed by fish, egg and peanut. Respondents were satisfied with the current font size and general information provided in food labels. Respondents agreed that it could be problematic to identify suitable foods for individuals suffering from food allergies or intolerances. Variations of PAL statements and generic terms provided in food labels, and location of allergy warnings were cause for concern. More than 80% of the respondents felt that allergens in ingredient list should be emphasised (e.g. bold font) and plain English or French language should be used to describe allergenic ingredients. The findings in this study provide practical insights on food allergen labelling issues for policy makers and stakeholders in the food supply chain. Determining the prevalence of food allergies in the country will inform policy makers to consider adding shellfish and other major allergenic ingredients to the list of ingredients requiring mandatory allergen warning label in Mauritius.
Article
A diagnosis of food allergy adversely impacts one's ability to join or remain in the military. Inadequate knowledge or misconceptions of current military-specific standards regarding food allergy and how these apply to enlistment, induction, and retention in the United States military can potentially lead to inaccurate counseling as each military service has specific regulations which impact the evaluation and decision-making process. Recognizing this knowledge gap, the American Allergy, Asthma, and Immunology (AAAAI) Military Allergy and Immunology Assembly (MAIA) established a Work Group who reviewed and summarized all aspects of military instructions, policies, and regulations regarding IgE mediated food allergy. A flowchart was developed outlining each step of the military entry process for an individual with a history of food allergy. Further, summary tables were made to provide improved "fluency" regarding each service's medical regulations while key considerations were outlined for the allergist who is evaluating an individual who is seeking military entry or retention. Both civilian and military allergists play an essential role in the evaluation, counseling, and management of patients with a food allergy history. Understanding the service-specific language and regulations regarding food allergy will improve the allergist's awareness, counseling, and management of these individuals.
Article
There is an increasing number of food allergic reactions occurring in food services including takeaways. This study investigated the food allergy knowledge, attitude and practices of staff in takeaways. Although more than half of the takeaways’ staff (n=28) demonstrated good food allergy knowledge, there still exists some misunderstanding among the respondents. There were confusion about lactose intolerance and milk allergy, a third of the takeaways’ staff were uncertain that hands could transfer allergens. Almost half of the respondents were not aware of the danger of offering water to dilute a food allergen to stop the reaction Experienced staff and managers / owners reported more positive attitude and higher frequency of good food allergen management practices. Respondents also strongly agreed that customers should inform staff if they have food allergies. However, takeaways’ staff would enquire customers if they need allergen information when taking orders over the telephone. Clear communication between front service staff, customers and kitchen crew are important and should be established and meals verified with cooks to ensure safe meals are prepared. Managers or owners should also strongly encourage their staff to participate in food allergy training. Food Standards Agency has set up a free food allergy online training that would be a valuable addition to food businesses.
Article
This review provides general information to serve as a primer for those embarking on understanding food allergy and also details advances and updates in epidemiology, pathogenesis, diagnosis and treatment that have occurred over the four years since our last comprehensive review. Although firm prevalence data are lacking, there is a strong impression that food allergy has increased, and rates as high as ∼10% have been documented. Genetic, epigenetic and environmental risk factors are being increasingly elucidated, opening the potential for improved prevention and treatment strategies targeted to those at risk. Insights on pathophysiology are revealing a complex interplay of epithelial barrier, mucosal and systemic immune response, route of exposure and microbiome among other influences resulting in allergy or tolerance. The diagnosis of food allergy is largely reliant on the medical history, tests for sensitization, and oral food challenges, but emerging use of component resolved diagnostics are improving diagnostic accuracy. Additional novel diagnostics such as basophil activation tests, determination of epitope binding, DNA methylation signatures and bioinformatics approaches will further change the landscape. A number of prevention strategies are under investigation, but early introduction of peanut has been advised as a public health measure based on existing data. Management remains largely based on allergen avoidance, but a panoply of promising treatment strategies are in phase 2 and 3 studies, giving immense hope that better treatment will be imminently and widely available, while numerous additional promising treatments are in the preclinical and clinical pipeline.