Clinical Challenges: As Food Allergy Treatment Evolves, Disparities Persist

For people with food allergies, socioeconomic variables such as access to medical care, education, and language remain hurdles to treatment despite advancements in the science.

“The first thing we have to talk about is just prevention,” said Michael Blaiss, MD, at the Medical College of Georgia at Augusta University, who said there are good data supporting early introduction of peanut and other foods to prevent food allergies in children. Yet “I don’t think the numbers suggest that we’re really reaching out to the lower socioeconomic population,” Blaiss told MedPage Today.

A national survey revealed that Americans of color and people with household incomes under $100,000 were more likely to have food allergies in recent years. Black individuals reported the highest rates of multiple food allergies, and Hispanic and Black individuals had the highest rates of past-year or lifetime emergency department visits due to allergies.

The CDC estimates that almost 6% of U.S. adults and children have a diagnosed food allergy — not counting those unable to get an accurate physician diagnosis due to a lack of access to specialist care.

One barrier patients may face when they seek care for their food allergies is language. A study showed that among children indicating a preference for another language over English, the chances of being correctly diagnosed with a food allergy were roughly half that of their counterparts.

Hao Tseng, MD, of SUNY Downstate Health Sciences University in New York City, explained that addressing language barriers is a matter of resources, as some hospitals may not have interpreters available. “It’s one of the factors that’s contributing to underdiagnosis of many diseases, including in immunology and allergy,” Tseng said.

Even if a food allergy is diagnosed, there are other ways that socioeconomic disparities can show up in food allergy treatment and management.

The milestone FDA approval of a peanut powder for oral immunotherapy (Palforzia) in 2020 marked a formal shift from conventional allergen avoidance to a proactive desensitizing of children and adolescents.

While some clinics had long offered oral immunotherapy with inexpensive peanut flour and other ingredients, the approved product was marketed as having the advantage of being a standardized treatment across practices. But early uptake of the approved, purified peanut protein product has been notably slow. Even if cost and risk profile are considered acceptable, there are the downsides in convenience: a dosing schedule requiring many office visits and an indefinite home-dosing period.

Biologic therapies show promise to be another paradigm shift in treating food allergies.

Yet Ruchi Gupta, MD, MPH, of the Northwestern University Feinberg School of Medicine, Chicago, stressed the importance of addressing health disparities as more treatments for food allergies appear on the horizon.

“We have a ton of treatments that may be available in the next couple of years. But right now, it’s mainly out of pocket,” Gupta said. “Are we going to increase the current disparities that we have? For some reason, prevention is happening less, and then treatments may be hard to access on the other end. Those are my biggest concerns.”

Even traditional allergen avoidance can be easier said than done for many people.

With rapidly changing grocery prices, rising food insecurity, as well as the fact that some allergen-free item swaps — such as almond butter or non-nut butter for peanut butter — may be more expensive than their counterparts, avoidance becomes more and more difficult for some patients and their families.

“Let’s face it, at cost, peanut butters are cheaper,” said Blaiss, and the same thing goes for milk. “Soy milk or almond milk or any of those other milks are going to be more expensive than cow’s milk.”

In response to a proposed rule by the U.S. Department of Agriculture’s Food and Nutrition Service to revise product coverage within the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), the patient advocacy group Food Allergy Research & Education said it submitted comments recommending inclusion of peanut and other food allergens in the infant food package to reduce the risk of developing allergies, and greater flexibility in WIC for allergen substitutions.

Both Gupta and Blaiss suggested that policy-based changes regarding allergen-safe foods and future allergen treatments, may help disadvantaged groups.

Gupta said that “thinking outside of the box” and meeting people where they are can help spread awareness about food allergy and its associated disparities, as well as empower primary care providers.

“I would love to see a food-and-medicine type of policy for Medicaid so that kids can get access to safe, healthy foods that don’t have their allergen in it,” she said. And for medications, Gupta said it would be great if Medicaid and other policies covered new treatments as soon as they become available in order to be accessible to different groups.

Arabelle Abellard, MD, of Rush University in Chicago, cautioned that insurance alone doesn’t fix access issues in receiving allergy care.

“Even if someone has insurance that covers services or provides coverage for their family members, there are other healthcare-related costs,” she said, such as transportation or needing to take time away from work. “That’s a huge factor.”

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