Adherence to restrictive diets and immunotherapy regimens can be challenging for patients and their families, and patient-specific factors can compound these challenges. Ruchi Gupta, MD, MPH, discusses several adherence challenges in the management of food allergies, including those related to precautionary allergen labeling (PAL), and opportunities to address these challenges.

For patients with food allergies, adherence to specific diets can be challenging. Many children are allergic to multiple foods. Common food allergens are peanuts, tree nuts, milk, eggs, soy, and wheat. It is very challenging to avoid some of these foods every single day in all meals, and this can be even more difficult for families who are of a lower socioeconomic status.

Something that I think is also very important is what families do with PAL. PAL is not mandated but is on the packaging of many foods, with verbiage such as “may contain . . .” or “made in a facility that also makes. . . .” PAL is really challenging because it is very hard to avoid while also being very hard to understand. Further, there are no threshold amounts of allergens associated with the labeling.

How do we get this changed? Regulating PAL is a big policy issue, because getting safe foods to eat is very challenging. There is a big push to measure the allergens in foods and put threshold amounts on PAL. If PAL included threshold amounts, then a patient could go to their doctor and eat a minute amount of the allergen up to that threshold, which may be 1/20 of a peanut, for example. If they tolerate that amount, then they could be cleared to eat foods with PAL, and it would give them comfort.

We conducted a survey to see what people do with regard to PAL, and it is all over the place and is very dependent on shared decision making with allergists. Some avoid all foods with PAL, and others avoid only certain foods with PAL. A lot of patients will tell you that they will just continue eating a food that they have consumed before; if it is a new food, then they may avoid it. If you tell certain patients to just always avoid foods with PAL, which is probably ideal but very difficult, they will do it. What I have seen in general is that, when allergists talk to their patients about the different foods that they are allergic to, they may say that some of the foods are okay and some should definitely be avoided if there is PAL on them.

The availability of biologic therapy for food allergies could really help because it can increase the threshold of tolerance to the allergen. It is not a cure, but it allows some people to eat a certain amount of the allergen so that they do not have to worry about PAL, cross-contact, or a reaction to a small amount of food. The challenge is that biologic therapy does not work for everyone, so getting more data is necessary to really know for whom it may work. Also, it is an injection that has to be administered regularly to keep that threshold up, so adherence is important.

Adherence to oral immunotherapy (OIT) is very burdensome for a couple of reasons. One, when a patient starts on OIT, there is a requirement to take it daily, and there are often exercise restrictions around the time of dosing, which is not easy for families to regularly monitor, especially with multiple caregivers. In addition, the administration of OIT may cause reactions; they may be mild, but they can impact adherence to subsequent doses. OIT regimens can also be harder for low-income families and for people with lower health literacy.