A new observational study has linked college dining hall preparedness with outcomes for students with food allergies. 

“This study highlights the need to improve food allergy management in college campuses by enhancing cross-contamination safety, staff training, stock epinephrine availability, recipe consistency, and accurate allergen labeling,” wrote Ashna Jain, MD, and her colleagues. Jain is a physician in the Department of Pediatrics at the University of Michigan in Ann Arbor. 

Their study was published online in JACI Global.

The estimated portion of college students in the US with food allergy is around 15%, yet in college dining halls, the risk of food allergy, anaphylaxis, and related outcomes remains unknown. Recent data suggest that only two-fifths of college students with food allergies consistently maintain vigilance around their allergens, and anywhere from less than 10% to 20% of college students with a known food allergy carry their epinephrine injector. 

“College students are particularly vulnerable to allergic reactions due to being in a new environment and eating in common areas such as dining halls. Many college students assume responsibility for their health for the first time, and navigating food allergies in dining halls can thus be a challenge,” Jain et al wrote.

To describe the connection between food allergen risk and a dining service’s preparedness to handle anaphylaxis, Jain and her colleagues examined survey data of incoming freshmen collected by the University of Michigan’s dining services in September 2023. Because these surveys asked only about dietary restrictions, not demographic data, the investigators included demographic information in their survey of the entire incoming fall 2023 freshman class for context.

There were 7466 students in the incoming class, with nearly all enrolled full time (n = 7426; 99%). There were 4049 women (54%) and 3417 men (46%). White/Caucasian students were the largest group (n = 3346; 44.8%), followed by Asian Americans (n = 1511; 20.2%) and Hispanic Americans (n = 1099; 14.7%). Black students were 5.8% (n = 432), with the remainder identifying with smaller groups.

In all, Jain et al found a 6.6% prevalence of self-reported food allergy across the incoming class. The figure is lower than national estimates, the investigators noted — likely reflecting self-reporting and sampling biases — but still consistent with the ASSESS FA study, which reported a 6.6% prevalence of physician-verified food allergy in US adults across multiple countries. 

Of the 7466 enrolled first-year students, 1325 (18%) completed the survey. Of these, 898 reported having dietary restrictions, with 406 of this group also reporting additional dietary restrictions such as being kosher, halal, or gluten-free. The remaining 427 of the entire group reported having no dietary restrictions, leaving 492 individuals that reported a dietary restriction due to self-reported food allergy (37% of total survey respondents and 6.6% of the total incoming first-year class). 

The investigators also reviewed self-reported surveys of allergic reactions occurring between August 2019 and September 2023 on the University of Michigan campus. 

There were 53 dining hall reactions presenting with emesis, hives, difficulty breathing, and itchy throat. The most common triggers were tree nuts (n = 12; 23.1%), peanuts (n = 7; 11.5%), and milk (n = 8; 15.4%). Epinephrine was used in 14 (26%) of the cases, 10 of which came from personal autoinjectors and four from university stock. Recipes linked to tree nut and peanut reactions showed high rates of label (78%) and recipe compliance (89%). 

“Both peanut- and tree nut-containing foods in this study had high rates of proper labeling and recipe compliance. In contrast, foods containing allergens not included among the top nine (peanut, tree nuts, milk, egg, fish, shellfish, wheat, soy, and sesame) may carry a higher risk for accidental exposure, as labeling regulations often focus on these primary allergens,” Jain and her coauthors wrote. 

A 2023 study, which found 69% of students who endorsed learning how to respond when a person is experiencing anaphylaxis, also indicated that increased awareness about food allergies might improve quality of life on campus. Jain et al concluded that, “Universities and dining services together bear responsibility to ensure that the proper measures are in place for students with food allergies.”

Malika Gupta, MD, director of the Food Immunotherapy Program at UT Southwestern in Dallas, said, “While we clearly see from qualitative studies and surveys that the risk [of anaphylaxis] goes up, we still don’t have strong quantitative data on exactly how much it rises. What we can say is that college students with food allergies run into more risk simply because their world changes overnight.”

They’re suddenly in a new environment, managing their allergies without the structure of home, and most of their meals come from dining halls or shared kitchens where food is prepared by someone else, she said. “That uncertainty alone makes avoidance harder.”

Gupta is also an associate professor in the Department of Pediatrics at UT Southwestern Medical Center, where she specializes in allergy and immunology. 

Gupta offered insights for clinicians treating this patient population. “Especially in primary care, it’s important to remember how much augmentation factors can intensify reactions. Exercise, illnesses, stress, lack of sleep, alcohol, and certain medications like [nonsteroidal anti-inflammatory drugs] all lower the threshold for a reaction. This matters significantly in college settings, where late nights, sports, and social drinking are common. A food that caused only mild symptoms in the past can trigger something much more serious when an augmentation factor is present. Bringing these issues up directly with patients can make a big difference.”

Jain had no relevant disclosures. Gupta disclosed she receives grant/research support from the American Academy of Asthma, Allergy and Immunology and DBV Technologies. She also serves on the medical advisory boards of the International Food Protein-Induced Enterocolitis Syndrome (I-FPIES) Association; Alerje, Inc; and Stallergenes Greer. She is a board director for the I-FPIES Association.