Sunday, January 27, 2008


Follow-Up Interview Scheduled for WNYC this Thursday


This post is long, but I hope it's worth putting on the Web. It's basically a critique of a Harper's item that consists largely of unsubstantiated criticisms of the Food Allergy and Anaphylaxis Network (FAAN), which to the best of my knowledge remains an excellent resource for people seeking reliable and scientifically supported information about food allergies. (I expect that much of this will be addressed on Thursday on WNYC's The Leonard Lopate Show, which has arranged a 12:40 pm interview with the well-regarded allergist Dr. Hugh Sampson (right) in response to the outcry over the Harper's piece and Lopate's subsequent interview with the piece's author, writer Meredith Broussard.)

I am not a member of FAAN, but I'm close to one person who is. She became part of the group after her child was diagnosed at a very early age with serious allergies to eggs, wheat, and dairy. FAAN, which was itself still in its infancy, helped this new mother learn how to manage the situation inside and outside her home by reading labels, being prepared to use an EpiPen in case of anaphylactic shock, and communicating her child's needs to others in their immediate and extended communities, where they lived and where they traveled.

Knowing of this very positive experience with FAAN, I've referred to the organization in this blog, mainly when writing about the current scientific understanding of spelt being prohibited on wheat-free and gluten-free diets. I've also considered FAAN to be a model organization when it comes to informing the general public about food allergies and facilitating communication among families, medical professionals, and others in the food allergy community. In a world where there is a lot of misunderstanding about allergies (and a lot of vagueness as to what does and does not qualify as a food allergy), I am sure that FAAN has helped countless people with food allergies to stay healthy and well-informed about their conditions.

That's why I was surprised to learn about the hostility towards FAAN in the January 2008 Harper's. The item in question, "Everyone's gone nuts: The exaggerated threat of food allergies," might look, at a glance, to be a six paragraph dissection of an FAAN pamphlet. But on closer inspection, it turns out to consist largely of a bunch of vague and insufficiently supported claims that could do more harm than good. I join with many people in finding the article to be seriously flawed, yet I've seen Harper's itself trumpeting the article on its homepage as "One of the reasons why HARPER'S is essential reading."

I think not.

In the first paragraph, Broussard writes the following:
Of little concern to most parents or educators only a generation ago, food allergies are now seen as a childhood epidemic. The American Academy of Pediatrics recently began recommending that peanuts be withheld until a child turns three; hundreds of food-allergy nonprofits and local parents groups have formed; and six states have passed laws requiring food-allergy safety measures in their schools, with similar legislation being considered in Congress. Children are even being recruited to help this supposed threat, as in this [FAAN] brochure, which enjoins young students to 'Be a Pal' and protect the lives of their classmates. But the rash of fatal food allergies is mostly myth, a cultural hysteria cooked up with a few key ingredients: fearful parents in an age of increased anxiety, sensationalist news coverage, and a coterie of well-placed advocates whose dubious science has fed the frenzy.
I won't take issue with Broussard's catalog of things being done on behalf of children with allergies. I'm open to AAP recommendations, the formation of parents groups and food-allergy nonprofits, legislation to protect students who have allergies, and brochures that encourage students to look out for the health of their classmates. Aren't you?

What I do question is Broussard's framing supposition—that food allergies are seen as an epidemic—and her corollary pronouncements regarding a mythical rash of fatal food allergies concocted by fearful parents and dubious science as well as sensationalist media coverage. I don't see any support for a claim that any reasonable party sees food allergies as an epidemic (as opposed to a significant health issue), and, as will be shown, I mainly attribute the brochures, legislation, advocacy groups, and AAP recommendations to concerned parents and mainstream, supportable, science—not to quackery or sensationalist news coverage.

Broussard continues by contending that "FAAN has successfully passed off as fact its message that food allergies have become more prevalent and dire." Yet the following statements do not support her contention; they merely make a mountain out of a statistical mole hill.

Broussard writes
Since 2005, more than 400 news stories have used FAAN's estimates that allergic reactions to food send 30,000 Americans to emergency rooms each year and that 150 to 200 ultimately die. The group derived these figures from a 1999 study of a rural Minnesota community, in which 133 people over a five-year period were determined to have suffered anaphylaxis—an allergic reaction that can mean everything from going into shock to developing an itchy mouth. Yet only nine people in the study ever required hospitalization for anaphylaxis from any cause. As for the death estimate, just one person died of anaphylactic shock, prompted not by food allergies but by exercise. The Centers for Disease Control and Prevention, in its most up-to-date figures, recorded only 12 deaths from food allergies in all of 2004. When asked about these statistical discrepancies, FAAN founder and CEO Anne Muñoz-Furlong said focusing on any number misses the point: "One child dying from food allergies is too many."
I've read that Broussard misused her CDC figures, but even if her numbers hold up they do not necessarily make a case that FAAN exaggerates the threat of food allergies to any significant extend. Let's compare FAAN's upper-range figure of 200 deaths to the figure of 12 offered by Broussard. In some situations the difference of 188 people might seem huge, but in this case it's a difference of 188 in a population of about 301,139,947. So FAAN says that, at worst, about 0.006641% of the population suffers fatalities, while the CDC says that 0.000398% of the population suffers fatalities. Neither the FAAN figure nor Broussard's CDC figure would seem to be what health policy makers might consider to be a high priority or what Broussard dubs "a statistical discrepancy."

Nevertheless, the saving of even one life in 301,139,947 can (and should) still be viewed as having a very high value. So it's understandable—and very honest—for the head of FAAN to take the position that "One child dying from food allergies is too many" in justifying the kind of education and preparation and policy-making that FAAN advocates.

Furthermore, Broussard makes what I call a "fatality fallacy," focusing on death as opposed to the overall impact of a health concern. Whether or not one considers any number of deaths prevented by the use of EpiPens and other procedures advocated by FAAN, it would still be misleading to evaluate food allergy policy only in terms of fatalities, when the actual experience of having a food allergy has more to do with preventing an array of alarming symptoms, non-lethal as well as lethal. This point of view is especially relevant to those of us who have celiac disease, as we rarely risk anaphylaxis but nevertheless suffer significant health problems when our medical diets are violated.

Next, Broussard vainly gainsays this factual FAAN statement regarding kids with food allergies: "Sometimes, if they eat even a tiny amount of the food they're allergic to, they can become very ill ... even die!"

Broussard uses somewhat debunked reports of a single incident—of a teen girl with a peanut allergy (and asthma) dying after kissing a boy who had eaten peanut butter—to support her contention that "there is simply no evidence that a food allergen can do serious harm if not ingested." But the truthful FAAN statement did not even claim that a food allergen could do serious harm if not ingested, and it did not refer to the "kiss of death" story.

Even Broussard's use of the "kiss of death" anecdote is problematic. As pediatric allergist Dr. Mike Pistiner told Sloane Miller (a.k.a. Allergic Girl, right) at
Allergens can be transferred through saliva, so the second-hand exposure threat is real but entirely avoidable. Rosemary Hallett and colleagues at the University of California Davis School of Medicine reviewed data collected on 379 subjects with self-reported immediate nut or seed allergy and found that 20 subjects (5.3%) reported that they experienced reactions from kissing. Most of these reactions were mild but 20% did experience respiratory symptoms (Hallett et al. N Engl J Med 2002; 346:1833-4). Studies in other countries showed that people with food allergies reported that they experienced allergic symptoms after having "close physical contact (for example, kissing) with someone who recently ate something they were hypersensitive to(Eriksson et al. Journal of Investigational Allergology and Clinical Immunology. 2003 13(3):149-154).

In 2006, Maloney and colleagues conducted a study measuring the amount of peanut protein in 1 ml of saliva at certain times after eating a peanut butter sandwich and following various interventions. The study showed that soon after eating peanut butter salivary levels of peanut protein were high enough in some to cause a reaction. Additionally, 13% of subjects had detectable peanut protein in the saliva after 1 hour. No subjects had detectable salivary peanut protein several hours later and after eating a peanut-free meal. This study supports the reports of patients experiencing symptoms after kissing and demonstrates that oral contact with saliva, such as from sharing utensils or cups, can contain significant amounts of allergen and should be avoided. Additionally this study gives some guidance as far as interventions that can reduce the risk of a reaction other than complete avoidance (Maloney et al. JACI. V 118, (3) 719-724).
Broussard writes triumphantly that asthma was the real cause of the teen girl's death, but she does not address the possibility that asthma can be part of an anaphylactic reaction. As Pistiner tells Miller:
Anaphylaxis can trigger asthma attacks that are notoriously difficult to treat. Wheezing, cough, chest tightness, and shortness of breath commonly occur during an asthma attack but are also life threatening symptoms seen during anaphylaxis (Wang. Clinical and Experimental Allergy, 37, 651-660). In some cases, respiratory symptoms can be the only manifestation (Moneret-Vautrin et al. Allergy. 2005: 60: 443-451). Anaphylaxis presenting in this way must be quickly treated with epinephrine. Prior to the advent of albuterol, epinephrine was the drug of choice for asthma exacerbation. When in doubt, use your epinephrine and call 911.
That, incidentally, is precisely the type of lifesaving information that FAAN offers.

In Broussard's attempt to criticize FAAN, she names it as one of an unspecified number of organizations that have helped changed the perception of food allergies to something resembling "a Newsweek cover (pictured) showing a pigtailed girl in a gas mask with a carton of milk in one hand and a peanut-butter sandwich in the other." Then she writes "But all we know for certain now is that more parents think their children suffer from food allergies." But Broussard doesn't substantiate that grand statement—and she doesn't seem to show any awareness that FAAN actually educates parents about what is and isn't a true food allergy.

Surveying incidents of "chumminess...within the world of food-allergy advocacy," Broussard writes that FAAN's sponsors include pharmaceutical companies with interests in devices such as the EpiPen, but fails to specify how this situation—typical in the health field—involves anything reprehensible.

She also notes that "Just about all the leading food allergists also have ties to FAAN or the Food Allergy Initiative (FAI)." I'd imagine that ties with leading food allergists would be a very good thing, but Broussard seems to think otherwise: "This intimacy helps explain why suspect statistical findings get published." But she doesn't offer such suspect findings. Instead, she writes "For instance, the coauthors of an oft-cited study on the dangers facing food-allergic children at restaurants were Anne Muñoz-Furlong's husband, who serves as a top FAAN executive, and a FAAN medical board member whose research is funded in part by FAI. The latter is also an editor at the leading allergy journal where the study appeared; the journal's editor-in-chief is head of FAI's medical board." That's not much of a "For instance," since it only shows the chumminess but offers no examples of "suspect statistical findings" being in the oft-cited study. I am sure that FAAN is not above criticism, but it really seems to be above Broussard's criticism, which lacks substantiation.

Broussard starts her conclusion by writing "There is no question that food allergies are real. Yet instead of creating the healthy, happy children shown here, exaggerating the threat may actually do as much harm as the allergies themselves." She then refers to anxiety and fear among food-allergic children, and adds that "Such psychological distress is exacerbated by parents, who report keeping their children away from birthday parties and sending them to school in 'No Nuts' T-shirts." Wrapping up, she alleges that, "Having been fed a steady diet of fear for more than two decades, we have become, it appears, what we eat."

There is some sense to Broussard's conclusion, but it too suffers from poor and unsupported rhetoric. I have no doubt that some children with food allergies suffer from disproportionate fear and anxiety and that the behavior of some parents feeds into it. However, she provides no persuasive argument for generically laying the blame on parents. Neither does she offer a persuasive argument that blame should be laid on FAAN and its alleged embrace of "dubious science," when FAAN actually relies on current allergy research and consistently encourages parents to consult with medical professionals.

Perhaps incidentally, Broussard does a somewhat better job with her opening allegation that sensationalist news coverage is a key component of misapprehensions about food allergies. Stories like the "kiss of death" and images like that of the Newsweek cover show how media can wallow in rarities and extremes instead of sober coverage.

But Broussard's own article typifies another kind of problematic media trend: generically portraying people on medical diets as misguided. Claiming to be against sensationalism and ungrounded fear, she chooses the wrong target in FAAN, which is grounded on medical research. Recognizing that there are indeed children with serious food allergies, she shrugs off the seriousness of those allergies and consequently heightens suspicions that people claiming food allergies are deluded or exaggerating, possibly making it harder for people with true food allergies to let go of their fears and anxieties and trust others with their health.

The outcry over Broussard's opinions swelled considerably when she followed up on the article with a one-on-one interview on WNYC's The Leonard Lopate Show. There have been more than 190 comments in response, most of them critical of Broussard and Lopate, who hit a low point when he thoughtlessly chuckled while imagining a food allergy challenge that involves the child trying the food in question while being watched for a severe reaction. (This type of testing can be very frightening.)

For a while after the radio interview, Broussard allowed comments to appear on her blog, but after the mostly critical comments showed up she appeared to consign them to the Memory Hole, disabling the comment function.


ben cappel said...

Well done, David! I can hardly believe the nonsense Harper's printed. Editorial standards?? Sounds almost like Rush Limbaugh ghost-wrote that article.

David Marc Fischer said...

Thanks, Ben! I can hardly believe you made your way through the whole post. Even if you only scrolled and skimmed, that's impressive!

And congrats on today's Meetup.

thatgirl said...

reading FAAN site - is celiac considered an allergy or an intolerance?

David Marc Fischer said...

Hi, thatgirl. The language for both allergies and celiac disease leaves a lot to be desired. That applies both to popular usage and conventional medical usage.

Currently, the medical consensus seems to be that celiac disease should be considered an autoimmune disease rather than a food allergy or intolerance. Unlike an intolerance, celiac disease involves an autoimmune reaction and physical damage, but with celiac disease the reactions to gluten contamination is slower, or less immediately dramatic, or perhaps more insidious, than the reactions associated with a food allergy, which can result in anaphylaxis. Also, while some food allergies can be outgrown, celiac disease is apparently a lifelong condition.

It is also possible for someone to have celiac disease as well as one or more food allergies. (Keep in mind that I am referring to conventionally defined celiac disease and food allergies--the type diagnosed by mainstream doctors using conventional methods.)

Of course, anyone diagnosed with celiac disease and/or food allergies should maintain an appropriate medical diet.

Allergic Girl said...

great job david for breaking it down.

i agree on several points that broussard threw up alot of flags and then didn't take the inches to fully explore them.

will be very interested in dr. sampson's reply tomorrow on

David Marc Fischer said...

Thanks--and many thanks for your research!

Just for the record: I think Sampson will be on WNYC on Thursday, not Wednesday....

Canico~Gateway FEAST Co-Coordinator said...

I need your help...could you please go to the blog titled "The Mother Load" and help me tell these people the truth about Meredith Broussard's article! Her and her sister and really frustrating me. Her message was just posted yesterday. I would appreciate it. Thanks!
A mother with a child who has severe allergies to peanuts & egg.