At least eight foods currently not labeled as allergenic should be considered a risk for anaphylaxis and labeled accordingly in Europe, French researchers suggest.

Their study analyzed 2999 cases of food-induced anaphylaxis reported from 2022 to 2023 to the Allergy Vigilance Network, a public health surveillance network used across French-speaking countries. Any foods involved in 1.0% or less of reported cases were not considered to be emerging food allergens. The study was led by Dominique Sabouraud-Leclerc, MD, a researcher with the Allergy Vigilance Network.

Sabouraud-Leclerc and colleagues described 413 cases of anaphylaxis associated with foods not currently labeled as allergenic. Of these cases, 84 (2.8%) were from goat's and sheep's milk, 71 (2.4%) were from buckwheat, and 55 (1.8%) were from peas and lentils. 

Alpha-gal syndrome, a tick bite-related sensitivity to the sugar molecule found in red meat, was found to be associated with anaphylaxis in 50 cases (1.7%), pine nuts in 49 (1.6%), kiwis in 44 (1.5%), beehive products in 30 (1.0%), and apples in 30 (1.0%).

Alpha-gal-containing foods do not always result in an allergic reaction, Sabouraud-Leclerc and colleagues wrote, and as many as 80% of patients can resolve allergic symptoms with food avoidance. 

“The high rate of recurrence in our series (66%) is explained by the fact that most people are not aware of a potential risk linked to red meat, and by the late onset of reactions. Once the diagnosis has been confirmed and explained, avoidance is relatively easy, and the allergen is rarely masked,” the researchers wrote.

However, “given the severity and recurrence of anaphylaxis, and the possible presence of the allergen in masked form, we propose that…goat's and sheep's milk, buckwheat, peas and lentils, and pine nuts be considered for inclusion in the European mandatory labelling of foods list,” they wrote.

The View From the US

In an interview, Edwin Kim, MD, who directs the Food Allergy Initiative and is the division chief of pediatric allergy and immunology at the University of North Carolina in Chapel Hill, said the study mirrors what allergists are seeing in the United States. 

“Unfortunately, there’s a lot of crossover in animal milks, so we advise to not drink animal milks at all,” Kim said. “If we’re worried about anaphylaxis in a person allergic to cow’s milk, we are going to point them towards plant-based milks.”

As for legumes, as more pea protein powder is used in processed foods like meat substitutes and protein shakes, Kim said there has been an uptick in people presenting with legume-based allergies. 

Whether these foods should be labeled in the US, Kim said, it is a complex question. “If you label across all the legumes, for example, but only 5% of those people allergic are reactive to them, that can have some unintended consequences like creating fear.”

Mandatory food labeling might also backfire, he said. He recalled when sesame was added to the US federal list of foods that pose an allergic risk. Manufacturers, rather than testing to see if their products had sesame in them, began deliberately adding sesame so they could list it as an ingredient with confidence. “We didn’t anticipate that,” he said.

The net result was that even more products became off-limits to people with food allergies, Kim said. 

If a patient presents with food allergy-like symptoms to primary care and there is no clear history of exposure to the most common food allergens but the symptoms still fit “food allergy,” then consider calling in an allergist, said Kim. 

The study authors reported no disclosures. Kim reported relationships with ALK, Allergy Therapeutics, Cellergy Pharma, DBV Technologies, Genentech, GrowHappy, Hanimune Therapeutics, IgGenix, Phylaxis BioScience, Revolo Biotherapeutics, and Ukko; he also has grants from NIH and Food Allergy Research & Education.