Food allergy in college and university students: Overview and management

INTRODUCTION — Food allergy may affect 7 to 11 percent of college-age individuals [1,2] and can involve life-threatening or fatal reactions [3,4]. Teenagers and young adults appear to be at higher risk for fatal allergic reactions, possibly because of risk-taking behavior and reluctance to use epinephrine [3-6]. College years may be the first time that young adults are away from parent/caregiver supervision and fully responsible for self-management of their allergy. Risks of allergic reactions may be increased due to social pressures against proper allergen avoidance and prompt treatment, as well as factors associated with obtaining meals that are prepared by others.

This topic presents an overview of the prevalence of food allergy in teenagers, reviews data on fatal food-allergic reactions, describes food allergy attitudes and behaviors among teenagers and college students, focuses on risk-taking behaviors identified in this age group and possible approaches to reducing these behaviors, and discusses general strategies for managing food allergy in this age group.

This review also discusses the components of effective management of food allergy in colleges and the approach that students with food allergies and their parents/caregivers may take in preparing for college. Publications are available that provide further resources, such as college training instructions, as well as examples of materials provided by colleges. (See 'Resources' below.)

Other aspects of food allergy are presented separately. (See "Management of food allergy: Avoidance" and "Clinical manifestations of food allergy: An overview" and "Food allergy in schools and camps".)

OVERVIEW

Prevalence — Although studies are lacking to adequately document a potential rise in food allergy among college-age students, several studies suggest high rates of allergy in this age group, underscoring the need for management in colleges. The following observations about food allergy prevalence are especially relevant:

●A 2008 study involving self-reported prevalence of peanut and tree nut allergy in the United States found that 1.8 percent of 18 to 20 year olds were affected [7].

●A United States-based 2015 to 2016 internet and telephone survey of 8987 children 14 up to 18 years of age noted an overall food allergy rate of 7.1 percent as assessed by parental report of convincing symptoms [2]. The following rates of allergy to individual allergens were also reported: peanut 2.1 percent, shellfish 1.5 percent, cow's milk 1.1 percent, tree nuts 0.9 percent, fish 0.6 percent, hen's egg 0.5 percent, wheat 0.4 percent, and soy 0.2 percent. A 2019 study of adults aged 18 to 29 years identified a food allergy rate of 11.3 percent, with 2.7 percent having had onset in adulthood [1].

●It appears that an increasing proportion of childhood milk and egg allergies is persisting into adolescence and adulthood [8,9]. This is important because these foods can be especially difficult to avoid.

Fatal food reactions — Fatal food-induced anaphylaxis is most common in adolescents and young adults, although the exact prevalence is not known. A case series of fatal anaphylaxis suggests several aspects of relevance for teenagers and young adults:

●In two series of cases reported to a national registry with a total of 63 fatalities [3,4], 15 (24 percent) were college-age persons (ages 18 to 21 years). Including teenagers up to age 21 years, 48 deaths were noted, indicating a high risk among teenagers and young adults. The high number of individuals in the teenager and young-adult age group suggest that risk-taking behaviors may be involved.

●In the same two case series [3,4], the deaths occurred at school for 9 of the 15 college-age students. Of the cases with additional data available regarding location, one death was in a cafeteria, and three were in a dormitory or school apartment.

●The trigger foods for the 15 college-age fatalities were peanut (nine), tree nuts (five), and shellfish (one). The victims generally had underlying asthma, and only two received epinephrine earlier in the reaction. These data suggest that underlying asthma and delayed epinephrine administration are risk factors for fatal reactions.

Fatal anaphylaxis due to food-induced reactions is discussed in greater detail separately. (See "Food-induced anaphylaxis", section on 'Fatal reactions'.)

Risk-taking behaviors in adolescents and young adults — In an internet-based, anonymous survey of 174 adolescents and young adults (ages 15 to 21 years) with food allergy (49 percent male, 75 percent with peanut allergy, 87 percent prescribed self-injectable epinephrine), the following risk-taking behaviors were noted [5]:

●Thirty-nine percent did not carry epinephrine with them at all times. They were less likely to carry epinephrine depending on circumstances such as during sports, wearing tight clothes, being with friends, attending a school event, being at a bar or club, going on a date, being at a friend's house, or going to a party. Rates of carrying epinephrine autoinjectors were higher when the teens and young adults reported going to a restaurant or travelling.

●Thirty-eight percent did not have epinephrine with them during their most recent reaction.

●Only 64 percent indicated that they read food labels each time. In addition, 42 percent indicated that they ate foods when the label showed precautionary warnings (advisory labeling), such as "may contain" the allergen. Fifty-four percent reported eating at least a small amount of food known to contain their allergen.

The study identified a number of additional concerns among this age group that could lead to increased risk taking:

●Sixty-one percent of those not reporting prior anaphylaxis had described common symptoms of anaphylaxis, which suggests that many of the participants did not understand or recognize the term "anaphylaxis" or realize the severity of their prior reactions.

●As a group, 68 percent of the respondents felt that education of their peers about food allergy would help them cope better with their food allergy. This preference may relate to risk taking that results from attempting to fit in with peers who do not have food allergy.

●The 17 percent of participants deemed as "high risk" based on self-reported behaviors of eating foods with advisory labeling for allergens and not consistently carrying epinephrine were more likely to have experienced a recent reaction, suggesting that their behaviors resulted in reactions. In addition, they were more likely to describe themselves as feeling "different," which may translate into greater risk taking order to fit in.

A qualitative study interviewing 20 teens 12 to 18 years of age identified similar themes, including [10]:

●Deciding to carry an epinephrine autoinjector based upon risk assessment of specific situations

●Thinking that their risk varied depending upon the food allergen, such as feeling that peanut is riskier than fish

●Dissatisfaction with autoinjectors regarding size, complexity of use, and need to remember to carry them, as well as variable familiarity with activation of the device

●The findings that comfort with adherence is related to the attitudes of friends and emotional factors, such as feelings of embarrassment, affect adherence

Food allergy attitudes and behaviors among college students — A systematic review identified 20 studies related to attitudes, beliefs, and behaviors of adolescents with food allergy, identifying that these beliefs and behaviors could increase or decrease risks of reactions [11]. An online survey was conducted by email invitation to 14,990 undergraduate students older than 18 years at the University of Michigan, Ann Arbor [12]. There was a response rate of 3.5 percent (513 students). Among these, 57 percent reported a food allergy, and a total of 287 answered the survey questions revealing 104 (36 percent) had experienced anaphylaxis. Forty-two percent reported a reaction while enrolled in college. The data from this survey, although only from one campus and by self-report, suggest that college students may be taking serious risks, including lack of notification of the allergy, poor adherence to carrying medications, and risky eating behaviors.

Some of the key findings included:

●Among the students reporting a reaction at school, only 48 percent indicated that they had some type of medication available to treat the reaction, and only 21 percent indicated having epinephrine. Among the students reporting past anaphylaxis, only 40 percent reported having epinephrine, and only 6.6 percent responded that they always carry the device.

●Notification/communication of the allergy was poor, with 12.9 percent informing health services and 3.5 percent informing dining services.

●Only 40 percent of students reporting a food allergy always avoided the allergen.

A follow-up study at the same university after it instituted a program for comprehensive food allergy dietary/nutritional support and dining hall labeling showed modest improvements in the above parameters [13].

Insights on adherence to food allergy management in adolescents and potential interventions — Additional insights about adherence to food allergy self-management were identified in a questionnaire study of 188 teens from two allergy clinics in England who were aged 13 to 19 years, had a diagnosed food allergy, and had prior prescription of an epinephrine autoinjector [14]. Self-reported full adherence to carrying an epinephrine autoinjector and avoiding food allergens was identified in 16 percent of the participants. Multivariate analysis identified several factors associated with adherence: belonging to a support group, having an anaphylaxis management plan, perceiving the allergy to be more severe, and perceiving fewer barriers to disease management.

In another study of 59 adolescents from a food allergy clinic in New York City and their parents/caregivers, allocation of responsibility for identifying allergic reactions, following dietary restrictions, and explaining the allergy to others were surveyed along with measures of anxiety [15]. Patients and parents/caregivers generally reported shared responsibility over sole responsibility for the parent/caregiver or teen, but there was very poor correlation between the adolescent's perception and the parent's/caregiver’s report. Higher rates of adolescent self-responsibility (eg, for following diet) were weakly but significantly associated with higher anxiety, but it is not known if anxiety increased self-management or self-management increased anxiety.

A social media-based survey of 382 college students (51 self-reported food allergy) evaluated food allergy knowledge and management behaviors [16]. For those with food allergy, increased knowledge was related to better self-management behaviors (beyond prior reaction severity and allergic reaction rates). However, a case-control analysis of food allergy knowledge revealed that those with food allergy had statistically similar knowledge about food allergy as controls without food allergy. The study suggested that targeted education may improve management.

Epinephrine self-injection is a key management skill. A randomized trial (n = 60) of a medically supervised self-injection (using an empty syringe [plunger down, no liquid or air] with the adolescent asked to simply insert the needle into the thigh and then remove) resulted in improved self-reported comfort [17]. Additional studies are needed to validate the approach and evaluate for long-term changes in behavior.

MANAGING FOOD ALLERGY IN COLLEGE — Colleges should be proactive in planning how to help students manage food allergies. Planning ahead can result in a lower risk of allergic reactions and save valuable minutes needed to successfully respond to an allergic reaction. However, students must bear significant responsibility for self-management.

Student responsibilities and preparation — As reviewed above, the teenager/young adult must accept responsibility associated with allergen avoidance and recognition/management of a reaction. Self-advocacy is important because the student will need to communicate with personnel regarding obtaining safe meals. Avoidance and emergency response to allergic reactions are reviewed extensively elsewhere. (See "Management of food allergy: Avoidance" and "Prescribing epinephrine for anaphylaxis self-treatment".)

There are several aspects of avoidance that may require additional emphasis for adolescents and young adults:

●Acquiring or preparing meals on one's own. The increasingly independent young adult should be comfortable discussing allergies with food service, understand and accurately undertake food label reading, and avoid cross-contact with allergens during meals that are self-prepared.

●Alcoholic beverages. Alcohol can impair judgment, leading to greater risk-taking behaviors and failure to identify or treat an allergic reaction. Alcohol can also act as an eliciting factor, increasing reactivity to an allergen.

●Intimate contact. Food allergens can be retained in the saliva/oral cavity following a meal, and a partner with a food allergy can be exposed and react to this allergen during intimate kissing [18-20]. (See "Management of food allergy: Avoidance", section on 'Interpersonal contact'.)

In addition to self-preparedness, students and their parents/caregivers may wish to address a number of concerns related to food allergy management when away from home on college campuses. This additional preparation may entail investigating food allergy policies and meeting with key school personnel, perhaps early in the process of school selection and certainly following acceptance. Students and their parents/caregivers may wish to consider:

●Allowing additional time in the college search to address allergy-related issues

●Reviewing dining options and online menus

●Arranging to meet with the school's office of disabilities to discuss policies and procedures

●Arranging to meet with food service and addressing questions about their policies and training

●Reviewing housing options, such as the ability to store or prepare food in a dormitory or apartment setting

●Enquiring with the university health service regarding the management of medical emergencies on campus, specifically including hours of operation and their capacity to provide emergency care

Typically, documentation about the allergy will be required to obtain accommodations, such as allergen-safe meals. Once on campus, the student should maintain close communication with food, health, and residence life services. Students with food allergies should discuss their allergy with roommates and resident supervisors with an emphasis on allergen avoidance and what to do in an emergency, prepare for allergy management during parties, and have information (a written allergy emergency action plan) and emergency medications always on hand.

Institutional food allergy management plan — Students in higher education, while independent in many ways, still rely upon institutional policies and management to address safety. Food Allergy Research and Education (FARE) partnered with key stakeholders to create an educational resource page, "Navigating College" [21].

Specific policies and procedures may vary institutionally based upon resources and circumstances. Some typical areas of emphasis include:

●Having a confidential process for accepting and managing requests for accommodations and modifications based upon food allergies. Policy regarding documentation of the allergy may include review of statements from the treating clinician and consultation with student health services. In the United States, such documentation serves as the basis of need for accommodation/modification as defined by the Americans with Disabilities Act (ADA). This documentation ensures protection from discrimination and equal access through reasonable accommodations/modifications.

Accommodations are typically determined on a case-by-case basis and regard dining services (for example, to provide allergen-safe foods), residential life (for example, a room with space for food storage or preparation, training resident advisors), and academics.

●Having a campus emergency response plan that includes food allergies/anaphylaxis. This preparation may involve understanding how to activate emergency services, addressing how medication such as epinephrine may be provided, and training key staff, particularly dining services, residence supervisors, and emergency response teams.

●Having training, procedures, and policies in place to provide safe meals through the dining service. This includes the many details required in allergen avoidance such as control of ingredients, label reading, avoidance of cross-contact with allergen, clear communication, and specific cleaning procedures.

Personalized food allergy action plan — People with potentially life-threatening food allergies are encouraged to wear medical identification jewelry. In addition, colleges may benefit from receiving a copy of a personalized management plan to assist in documentation. Students may benefit from carrying this plan as part of their emergency pack. Action plan forms are available from Food Allergy Research and Education, the American Academy of Pediatrics, and the American Academy of Allergy, Asthma & Immunology (English and Spanish). While the standardized forms are preferred, easy-to-follow, written instructions from the child's clinician can also be used. A personalized action plan should include:

●List of foods to which the individual is allergic

●Signs and symptoms the individual might experience during an allergic reaction

●Appropriate treatment instructions from the treating clinician

●Emergency contact information

The plan should be reviewed and updated regularly to reflect any changes in the allergies or treatment plan.

OTHER CONSIDERATIONS

Roommates and campus housing — Options for housing for a student with food allergies could include a single room, having roommates, living on or off campus, having housing with a kitchenette, etc. There are no studies concerning relative risks of these or other options.

We favor an approach based upon risk assessment, communication, education, and cooperation. Decisions should balance the comfort of the student, the specific allergies, and other circumstances against risks associated with obtaining safe meals. Residence life, including dormitory living, having roommates, and taking meals in a dining hall, can provide important social aspects to college life. Having a roommate who is allergy aware could provide a level of security because this individual may assist in promoting allergen avoidance during social activities and be available to help should a reaction occur. We recommend that students discuss their options with their treating clinician, as well as campus staff.

Legal issues — Students with life-threatening food allergies are protected under federal civil rights laws, such as Section 504 of the Rehabilitation Act of 1973 [22] and the Americans with Disabilities Act (ADA) [23]. This is because a severe food allergy meets the legal definition of a "disability" or "handicap" (ie, a physical impairment that substantially limits one or more major life activities such as eating or breathing). The spirit of these two federal laws is essentially the same: to prevent discrimination on the basis of a disability. The major difference between the laws lies in their application. Section 504 applies to public schools and other institutions that receive federal funding. The ADA, however, typically applies to institutions that are privately run.

Colleges are not required to seek out students with food allergy (or other disabilities) to identify their needs. It is the student's responsibility to notify the school, typically the office of disabilities; to provide documentation; and to request any accommodations/modifications. Accommodations must be "reasonable," not creating undue financial burden on the institution or involving significant programmatic changes. Colleges run by religious organizations and receiving no federal funding are exempt from the ADA.

Resources — Various professional and governmental organizations have created guidance documents on food allergy management in schools, much of which may be applicable to higher education [24-28].

As noted above, Food Allergy Research and Education (FARE) created an educational resource page, Navigating College, that addresses management of food allergy in higher-education settings. FARE also created a college search tool summarizing food allergy accommodations at individual schools. In a review of 1200 schools, 94 percent had cross-contact procedures for made-to-order meals, 90 percent had preorder meals, 66 percent had allergy-friendly stations in the dining hall, 59 percent had online ingredient information, 22 percent had roommate accommodations, and 7 percent had stock, unassigned epinephrine available [29].

Strategies to reduce morbidity and mortality — The studies reviewed previously [14-16] (see 'Insights on adherence to food allergy management in adolescents and potential interventions' above) and others [5,10,12,30] suggest a number of interventions that could improve safety and food allergy management adherence in this age group. These include the following:

●Educate teens/young adults about the symptoms of anaphylaxis, not just the term "anaphylaxis," so that they are more likely to recognize and treat a serious reaction.

●Emphasize the need to consistently carry epinephrine autoinjectors (have them available at all times), and find ways to make this easier to do (eg, inconspicuous holsters). Carrying should not be related to self-perceived risk or social circumstances, because an accident could occur in any circumstance/location.

●Encourage wearing medical identification jewelry.

●Discuss and rehearse how and when to use epinephrine autoinjectors. Emphasize the importance of prompt use in the setting of anaphylaxis.

●Help teens/young adults understand that emergency response to a reaction (use of epinephrine) does not justify risk-taking behavior regarding dietary avoidance.

●Encourage peer education about food allergy. This can include increasing education on a school-wide basis.

●Provide a management plan in writing. (See "Food allergy in schools and camps", section on 'Personalized food allergy action plan'.)

●Discuss avoidance of allergens, risks of trace exposures, avoidance of products with advisory labels as required, and how to obtain safe meals in restaurants and cafeterias. Rehearse situation-specific decision making. (See "Management of food allergy: Avoidance".)

●Review and address emotional concerns, such as feeling different, that may affect risk-taking behavior. Address anxiety. Discuss issues openly and nonjudgmentally.

●Use online tools to improve knowledge.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Food allergy".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Beyond the Basics topics (see "Patient education: Food allergy symptoms and diagnosis (Beyond the Basics)" and "Patient education: Food allergen avoidance (Beyond the Basics)")

SUMMARY

●Prevalence – Food allergy may affect 7 to 11 percent of college-age persons, and case series of fatal food-induced anaphylaxis suggest that teenagers and young adults are a high-risk group. (See 'Prevalence' above and 'Fatal food reactions' above.)

●Risk-taking behaviors – Several studies suggest that college-age persons with food allergy take risks, including eating unsafe foods and not carrying or appropriately using emergency medications. (See 'Risk-taking behaviors in adolescents and young adults' above.)

●Approaches to improving adherence – In response to observed deficiencies with adherence, approaches may include education about specific symptoms, rehearsing the prompt use of epinephrine, encouraging always having epinephrine autoinjectors on hand, encouraging peer education, and addressing emotional concerns. (See 'Insights on adherence to food allergy management in adolescents and potential interventions' above.)

●General management of food allergies – Clinical management of teenagers/young adults with life-threatening food allergies focuses on allergen avoidance and prompt recognition and treatment of reactions. (See "Management of food allergy: Avoidance" and "Food-induced anaphylaxis", section on 'Issues in prevention and long-term management' and "Long-term management of patients with anaphylaxis" and "Prescribing epinephrine for anaphylaxis self-treatment", section on 'Key teaching points'.)

●Age and situation-specific management issues – Special management issues arising for college-age students with food allergies include being independently responsible for daily management, living in a social setting with peers, exposure to alcohol, and having intimate relationships with persons who may be ingesting an avoided food allergen. (See 'Student responsibilities and preparation' above and 'Roommates and campus housing' above.)

●Student role in preparation for management at college – Preparation for college campus management may include addressing medical management (proper diagnosis, treatment, documentation of the allergy), meeting with dining and housing services, and discussing any needed accommodations or modifications with the school. (See 'Student responsibilities and preparation' above and 'Legal issues' above.)

●Institutional role in management – Policies and procedures, which may vary by institution and circumstance, should address key factors including having a confidential process for managing requests for accommodations/modifications, campus emergency response plans, and dining services that can assist the student in obtaining safe meals. Institutions of higher learning must generally accommodate students with life-threatening food allergies, a disability protected by law. (See 'Institutional food allergy management plan' above and 'Legal issues' above.)

●Educational strategies – There are several educational strategies that may help decrease morbidity and mortality related to food allergy in this age group. (See 'Strategies to reduce morbidity and mortality' above.)