The ‘Big 9’ of Food Allergies with Jaclyn Bjelac, MD

Podcast Transcript

John Horton:

Hey there. Welcome to another Health Essentials Podcast. I'm John Horton, your host. Imagine starting every meal, every snack, every little nibble of food, wondering if one bite might hurt or kill you. That's a daily reality for anyone living with food allergies. More than 170 different foods have been found to cause allergic reactions. It's a wide-ranging list that includes many common refrigerators and pantry items, but there are nine foods in particular that are considered major allergens. That's what we're going to focus on today. Joining us is allergist Jaclyn Bjelac, associate director of the Cleveland Clinic Food Allergy Center of Excellence. Dr. Bjelac is one of the many experts at Cleveland Clinic who pops into our weekly podcast to help broaden our knowledge and understanding of health issues. So, let's take a look at the Big 9 nine of food allergens and learn a little more about the signs and risks of each. Dr. Bjelac, thank you so much for taking some time to be with us today.

Dr. Jaclyn Bjelac:

It's my pleasure. Thanks so much for having me.

John Horton:

So, I got to tell you, I've been really looking forward to this discussion. As we talked about earlier, I have a son with food allergies, and I know, when he was born and we started looking into it, we felt so isolated because it was not something that was talked about a lot. It seems like general knowledge of that has just exploded in recent years. What's been happening with that?

Dr. Jaclyn Bjelac:

John, thanks so much for sharing your perspective. I think it's a space where so many patients and families who are managing food allergies have come from. Unfortunately, food allergy prevalence is increasing, but thankfully awareness surrounding this diagnosis is also increasing. And I think as providers, doctors, nurses, we're doing a much better job of managing the whole patient. We're not just saying, "Here's your diagnosis, good luck," but we're really trying to empower families. There's a lot of literature that supports a really great multidisciplinary approach to food allergy, which is why we've been so excited to open our Food Allergy Center of Excellence at the Cleveland Clinic.

John Horton:

And I'm so glad that we have that because I know how important it is just within my own family. So, you talked about raising awareness and that is why we're here today and specifically to talk about the Big 9 of food allergies, which I guess there's real common foods that cause these problems. But I guess, before we kind of get into those specifics, can you walk us through what a food allergy is and why somebody's body might just respond so aggressively to a basic food item?

Dr. Jaclyn Bjelac:

Yeah, that's a great question. We could probably spend a lot of time talking about what is food allergy, and I tell my families, "If I knew why you have a food allergy, I'd have a Nobel." So here we are in a space where we certainly don't know everything, but what we do know is that when a patient has a food allergy, your immune system has identified a particular food protein as potentially dangerous, and when you eat that food, it creates a cascade of immune events that results in potentially serious life-threatening allergic reactions. So true, a food allergy is different than patients who are managing things like food intolerances or celiac disease, which are a very different process. It usually has more to do with digestion than the immune system itself.

John Horton:

There's a real irony there, in that your body is trying to defend itself against something that it sees as a threat, and by doing that, it actually puts you at risk.

Dr. Jaclyn Bjelac:

Yeah, it's really a hard space to come from when you're trying to explain it not just to parents, but also to young kids. Trying to explain to them, it almost feels kind of like your body is turning on you. And there's, unfortunately, a lot of disease processes in medicine where this happens. Autoimmune diseases, I mentioned celiac, it's really an autoimmune disease. Things like Type 1 diabetes, something's going wrong with the checkpoints in your immune system and it's attacking something that it's not supposed to.

John Horton:

What are some of the symptoms that people who have an allergic reaction show?

Dr. Jaclyn Bjelac:

So, food allergy reactions are not subtle. So, if a family comes to me and they're like, we're not sure if our kid has a food allergy, that actually decreases my level of suspicion quite a bit. So, when we're talking about true immune food allergy, typically within minutes, sometimes up to two hours after eating a food, a patient can experience a spectrum of symptoms. And the severity of those symptoms can depend on a lot of factors, and we're still learning a lot about this, but how much you've eaten, if you're sick or fighting off an infection, what else are you doing at the time that you eat that particular allergen, all of these things can impact reaction severity.

Food allergy reactions can impact every organ system in the body. We sort of typically think about hives, and absolutely they can be present. So itchy rashes that present immediately. You can have swelling of the mouth, tongue, of course, the throat would be a particularly concerning symptom. Some of our patients can have trouble breathing, and in very severe reactions, your body actually has trouble getting blood to all of your organs. You drop your blood pressure, and you can actually pass out. Thankfully, it is exceedingly rare, particularly in the United States, to have a fatal food allergy reaction. But certainly, patients and parents, that's, I think, something that underlies all of our worries as, "Could I die from this?" But thankfully that's very, very rare.

John Horton:

Yeah, and it is. It's very scary. And just living with it is, I know how scary it can be because you always have that fear.

Dr. Jaclyn Bjelac:

Yeah, and food's so social and we're constantly exposed to food. And as kids reach independence milestones, they're not eating with their parents as much. You're not always with them. It definitely is an anxiety-provoking condition for patients and families to manage.

John Horton:

At the start, I noted there's 170 different foods that people, I guess, have shown allergies to, but as I understand it, 90 percent of reactions are kind of linked to nine specific foods, the Big 9. So, let's break them down. Are you ready to jump into this?

Dr. Jaclyn Bjelac:

Let's do it.

John Horton:

All right. I've got my list here. So, let's start with milk.

Dr. Jaclyn Bjelac:

Yeah. So, milk's one of the most common food allergens in the United States, particularly in young children. Thankfully it's one that is typically outgrown by adulthood, though not always. The number that we give families is about 80 percent of kids would outgrow a milk allergy. Milk is a fickle, tricky creature because it can actually cause a lot of different types of reactions. So young infants can often have something called a "milk protein intolerance," where they get lots of stomach symptoms, they're fussy, gassy babies from milk exposure either from maternal breast milk or from a cow's milk-based formula. Most kids outgrow that. So, it's why it can be a really challenging time, particularly when you're not sleeping, in the infant period. Kids will outgrow that. And while it's very bothersome, it is not dangerous.

This is very different than a milk allergy in older kids. We often have to tease out, families will come with kids with symptoms of bloating or diarrhea after consuming select milk products. This is much more likely to be lactose intolerance than a true milk allergy. Kids who are truly allergic to milk will have those immediate symptoms that I mentioned. Very rarely would they be isolated from one part of the body like the gut or stomach. Though, certainly, if you're having any symptoms with food ingestion, that deserves talking to your doctor. But kids who have true milk allergies can't eat any form of milk. So not just drinking glasses of milk, but they can't have butter, cheese, yogurt, anything, and milk is in so many things. It can be extremely limiting and also very isolating. You can't have cake at birthday parties and things like that. So, milk is common, thankfully, frequently outgrown, but very, very impactful as all food allergies are. But milk in a particularly frustrating way.

John Horton:

How soon do kids usually outgrow that? Is there a certain age where if they're going to kind of overcome it, they do?

Dr. Jaclyn Bjelac:

So, every kid's different, and in the allergy world, we're able to track the level of allergy antibody that your immune system is creating to a given food. So, milk, for example, we can check your IGE, which is the allergy antibody. We can check your level of milk year to year and track it. And as that number starts to drop, typically by grade school age, we're able to try and reintroduce milk in as safe as possible.

John Horton:

OK. Well, it's always good to know that there's a good chance that you could outgrow it. So, moving on to another one, eggs, as I understand, is a big one.

Dr. Jaclyn Bjelac:

Yeah, egg is the second most common allergen, particularly in children in the United States. This is also one that most kids do outgrow. But again, while it's there, as you can imagine with all the different products that contain egg, whether they be baked goods or grandma's lasagna, it's extremely impactful. So, every food allergen is a challenge to avoid, but milk and egg can present particular challenges because they also tend to hide.

John Horton:

Well, it is really hard if you can't see it. Nuts or things like that you can clearly see. But like you said, if the egg's baked into something you don't know.

Dr. Jaclyn Bjelac:

Or something with an egg wash, things like that. And our patients with egg allergy, we tell them to avoid the whole egg yolk and whites. Thankfully, many kids with egg allergies and milk as well are actually able to tolerate baked forms. So, you can talk with your allergist about if your child might be a candidate to try baked forms of these foods. Chances are far more likely than not that the answer is yes.

John Horton:

Well, that's always good to know that there's maybe a little room in there, but I take it it's on a case-by-case basis.

Dr. Jaclyn Bjelac:

You bet. But just the idea of being able to expand the diet as much as possible can be really powerful. Get that birthday cake in there.

John Horton:

My son has an egg allergy, and that is always one of the hardest things because you can't have that sort of stuff. So, moving on to, I think the one that everyone thinks of when you talk about food allergies is peanuts.

Dr. Jaclyn Bjelac:

So peanut is a very common food allergen, particularly in the United States. It's one of the allergens that's best studied because, very different than milk and egg, it tends to persist lifelong. So less than 1 in 5 people would naturally outgrow a peanut allergy. Peanuts are actually legumes, but they get called a nut. Botanically, it's more closely related to peas, which I don't, many kids wouldn't be too sad to be allergic to peas, but it sort of gets lumped into that nut category. So peanut is a required label, all of the top nine allergens now are labeled, per the FDA. So, if you're eating a food processed or manufactured in the United States and it has labeled ingredients and it contains peanut, it must say so.

John Horton:

And that is, I know, is literally a lifesaver for people. I remember, as I said, when my son was really young, having to comb through, reading all the fine print, because it was before they had stuff highlighted. And it does make it so much easier to have these main allergens ID’ed.

Dr. Jaclyn Bjelac:

Such a layer of complexity for everything from grocery shopping to just picking out a snack at a ballgame, every label, every time. That's what we tell families.

John Horton:

Definitely. So now, you had already alluded to this, but next on the list is tree nuts and those are different than peanuts. So, what can you tell us about tree nut allergies?

Dr. Jaclyn Bjelac:

Tree nuts, in the United States, most reactions are due to cashew, pistachio and walnut and pecan. But also, many people are tested for almond, hazelnut, macadamia nut, Brazil nut, and there are others. But cashew, pistachio, walnut, pecan definitely constitute the majority of real allergens. What we've seen, especially recently, is if you test positive to almond and hazelnut, if you haven't ever eaten them before, it's actually pretty unlikely that you're truly allergic. And this sort of points out some of our limitations with diagnosing food allergy. We have no perfect test. The only perfect test is what happens when you eat it.

So, a lot of people come to us, and they say, “We were told we can't eat peanut or any tree nuts,” and we're able to have them leave eating at least more than when they came in. And almond and hazelnut are a really common example of that, among the tree nuts, which is always really exciting because if you read labels often as some of us do, you see that things are frequently labeled just for almond or just for hazelnut, particularly in candies, baked goods. So, it's really nice to be able to liberalize the diet for families even if they do have to avoid selecting tree nuts.

John Horton:

And I'd imagine tree nuts also pose a danger because they can also be hidden in baked goods or products that are just kind of out at a party and you don't know that they're in there.

Dr. Jaclyn Bjelac:

Absolutely. And as things are trying to move towards foods that are a little bit more nutritionally dense, tree nuts are being used more and more often. I had a kid come in who'd had a cashew encrusted chicken at a local restaurant. That wasn't something that they were serving when I was growing up. So, there's definitely some more exposure now. So, more opportunity for kids who are allergic to react.

John Horton:

All right. Well, let's move from land into water here with the next two, and one allergen would be shellfish. I understand this is one of the more common ones among all age groups, right?

Dr. Jaclyn Bjelac:

Yeah, so shellfish and finfish, but shellfish in particular is a relatively rare allergen, particularly in young children, which could be exposure related. I don't know too many 1- and 2-year-olds who are going for the shrimp tray at a party.

John Horton:

They are not clamming for that.

Dr. Jaclyn Bjelac:

Oh, John, I see what you did there. That was punny, but it does persist into adulthood. So many of our adult patients are managing shellfish allergy, as well as finfish allergy. So, you're absolutely right. And those remain top nine allergens in United States. They're required labels, and while they tend to be, from a day-to-day standpoint, a little less challenging to avoid compared to maybe a milk or egg, they can still be really impactful from a quality-of-life standpoint.

John Horton:

I thought I read somewhere, too, where even with shellfish, there's even more issues you see with that, even with the vapors when they're being cooked. Is that true?

Dr. Jaclyn Bjelac:

Yeah, so everybody should always talk about their particular situation with their allergist, but very few food proteins, like, float in the air trying to attack you. With nearly all foods, you have to actually eat the food to have a reaction. So, for example, little Johnny sitting next to a friend at school, the friend is eating a peanut butter sandwich, unless little Johnny smears some peanut into his mouth or into his eyes, no risk from just being around it. That differs from shellfish because actually while it's cooking, the vapors do aerosolize some of the allergenic proteins and some of our patients with shellfish allergy will actually have airborne contact reactions to shellfish.

John Horton:

Wow. Well, that's scary.

Dr. Jaclyn Bjelac:

It is scary.

John Horton:

To be honest.

Dr. Jaclyn Bjelac:

It's definitely scary for them, but I guess it's an excuse to not have to help in the kitchen. So, stay out of there.

John Horton:

Well, I love how you can find a silver lining in anything there! And looking at the other side of it, just, I guess, the finfish swimming around, are there certain ones there that people are more prone to be allergic to?

Dr. Jaclyn Bjelac:

Yeah, I think that mostly depends on regional differences, dietary practices, but you can react to any finfish, any of the white fish, like cod, tilapia, salmon is a relatively common one where we are in the United States, so you can react to any finfish. And most of the finfish have very similar allergenic proteins. So, if you're allergic to one, it's very likely that you would be allergic to others.

John Horton:

OK. All right. Well, now, we're going to switch back to land again, so we're jumping all over the place. So, wheat, tell us about wheat allergens and, in particular, how it's different from gluten sensitivity and celiac disease.

Dr. Jaclyn Bjelac:

So, wheat's even more of a fickle creature than milk, that we've already talked about, can cause lots of adverse reactions in the body. And it's absolutely worth mentioning. We're still learning so much about how our bodies respond to foods when we eat them, but what should happen is you should be able to enjoy a bagel or a piece of bread and nothing should happen other than you feel full. But with patients who have true wheat allergy, within a few minutes of eating the food, they would have symptoms of those allergic reactions that I mentioned, which certainly can include vomiting and diarrhea, but are usually also accompanied by some skin symptoms plus minus some breathing symptoms. And those, again, are potentially life-threatening. Individuals out there, kids, but often not diagnosed until adulthood who suffer from an autoimmune disease called celiac disease, and they're not able to properly digest a particular wheat protein. And it can lead to some pretty significant gastrointestinal effects, bloating, discomfort, diarrhea, poor growth. Once diagnosed, all you have to do is not eat wheat. And those symptoms thankfully resolve.

There are other individuals who we don't identify to have celiac disease but can have a lot of gastrointestinal symptoms after they consume wheat. We tend to sort of globally call these individuals non-celiac gluten intolerance, but it's probably a disservice. There are probably multiple different things happening, depending on the person, that we still have yet to figure out. But again, after they eat wheat, they can be very uncomfortable, might need to rush to the bathroom to have a bowel movement. They feel much better after the bowel movement, but it can be really challenging and hugely impactful on quality of life for these patients. Again, unfortunately, the only treatment is wheat avoidance. So really, sort of all of these things, the treatment is wheat avoidance, but for something like true wheat allergy, with it being potentially life-threatening, you really have to strictly avoid it.

John Horton:

Wow. It's hard to believe there's so many nuances and just that the body responds the way it does, just to wheat. Something that you just think of as this simple thing that's in food.

Dr. Jaclyn Bjelac:

Yeah, it's just a grain. It's just out there growing.

John Horton:

It is. And it looks so innocent out in the field.

Dr. Jaclyn Bjelac:

Blowing in the fields, amber waves of grain, it's hard because, especially for certain types of wheat intolerance, people can maybe tolerate unbleached wheat, or they swear they can eat wheat in different countries. So maybe it's something with the manufacturing or treatment of our wheat, we really just don't know, which can be so frustrating. But thankfully for these patients and their families, there are a lot of wheat alternative options now that simply weren't around even five years ago, but certainly a decade ago. So, kind of piggybacking on the trend of being gluten-free, you're able to find hopefully some really delicious wheat-free options.

John Horton:

Definitely. All right. And staying in the farm fields here, soy is, I guess, another big one.

Dr. Jaclyn Bjelac:

Soybean is a fairly common allergen in the United States, although probably a lot of the time, over diagnosed. So true anaphylaxis to soy is relatively rare compared to some of the other top nine, but absolutely can be present. Thankfully, it’s one, that if you do have, you tend to outgrow. One important thing to point out, and one of the major benefits I think of seeing a board-certified allergist, is many people are counseled to avoid anything labeled with soy, but most products are really over labeled. There are a lot of my patients who have soy allergies who are able to consume soy lecithin and even soybean oil, which can be found in a number of processed foods. So, thinking about, how can we restrict as little as possible safely? That can be really empowering to patients and families when we meet.

John Horton:

And it sounds like the way to figure that out though is to work with an allergist. This isn't something you just want to play around with at home to see if you can handle something.

Dr. Jaclyn Bjelac:

It's really hard because there's so many options out there to test for things like food intolerances, but then, what to do with that information, who knows? And food intolerance is very different from food allergy. And because allergy is a safety concern, every patient and family deserve to connect with a board-certified allergist. We're so lucky to work with so many awesome pediatricians and family practice doctors who are able to even order initial testing and things like that. But there are options for dietary expansion. There are some things you're likely to outgrow. How do we monitor that? And also, treatment options that your general provider won't be able to give you. So, every patient family deserves an allergist.

John Horton:

Now, a few years ago, we would've been able to stop this discussion right there because it was just the Big 8, but they added somebody. So now, it's the Big 9, with Sesame being the kind of newcomer to the group. So how did that end up getting in the group?

Dr. Jaclyn Bjelac:

Yeah, so sesame seed allergy is an emerging concern, particularly in the United States, and as of January 2023 as a required allergen label per the FDA. So, sesame is most commonly encountered in foods like hummus and tahini, but many families are familiar with sesame seed buns. Those were available when I was young, but we think with a shift for more dietary exposures. I didn't eat hummus when I was 2 and my 2-year-old loves hummus. So, exposures, and we know the allergy in general is increasing. We've seen a lot more sesame allergies. I personally see a lot more sesame allergy than I do of a lot of that top nine list.

So, sesame seeds and sesame seed oil and ground sesame and sesame proteins can be in a lot of foods. So, it was great that they added it to the label, but unfortunately, because so many manufacturers and companies have struggled with supply chains, they weren't willing to make sure that all of their supply lines were free of sesame when the label came out. So, it's actually been intentionally added by a lot of companies with the labeling law changes. So that's something that our families who are managing sesame allergy have had to navigate, unfortunately.

John Horton:

Yeah. Well, it's never easy as you navigate all of these ingredient lists of what you can and can't eat. So, every trip to the grocery store involves a lot of reading.

Dr. Jaclyn Bjelac:

Every label, every time. There are brands of bread that families, that was their go-to, they had sesame allergy and then they had to pivot. So definitely has presented a challenge, and I’m always in awe of our patients and families who navigate this in there every single day just like you and your family do, John.

John Horton:

Well, thank you. And we've gone through the Big 9, which anyone listening, you can understand that it involves so much food that we all eat, and that is just common in our kitchens. Which I guess leads us to the biggest question is, how can we all help people with food allergies stay safe and feel more comfortable if they're kind of at your house or at an event that you host?

Dr. Jaclyn Bjelac:

Yeah, I think that's a great question. The first thing I think is always to just be receptive to hearing about people's dietary restrictions and preferences and making sure that you have food prepared in a way that your guest is comfortable with. And if they're not comfortable asking, how can we make this so you're comfortable and, in the end, knowing that it's not about you if they elect to bring some of their own food or not eat something that you've prepared because it's not safe for them or they don't feel safe.

And many of our families with food allergies have experienced a situation where they got sick at a party, and it resulted in an emergency situation. Maybe they just don't want to have to navigate that at your house. So just hearing people, it's really unfortunate that despite the increasing awareness, I still have a lot of families tell me that there are family members who don't take their child's food allergies seriously and they don't feel safe having their child eat there, which is really sad. Food allergy can be so isolated. When you're with family and friends, I don't think anyone wants to make their guests feel that way at all. So, the biggest thing is to ask the patient or the parent, “How can we make this safe for you?” Because that answer is different for everybody with dietary restrictions.

John Horton:

I think the key to that, too, would be to keep ingredient labels around. If you are preparing something, don't just throw those out, keep it for somebody to look at just to make sure that it might be safe.

Dr. Jaclyn Bjelac:

Yeah, the new trend of putting all your snacks and beautiful clear containers in your pantry is aesthetically pleasing, but perhaps really dangerous for patients and families with food allergies. So, cutting out those labels and tapping them to the bottom or back of those containers, so anyone who might want to enjoy that food can make sure that it's safe.

John Horton:

OK. Any other tips you might have just to work with people that have food allergies or to try to make them feel more comfortable or just to make a safer environment?

Dr. Jaclyn Bjelac:

Yeah, that's a really important question, but covers so many different things. I think, at the end of the day, the most important thing is that patients and families just really feel empowered. So, keep going to different doctors, different allergists, until you find someone who can provide you with resources that you can turn to when these questions come up, “How do I advocate for myself when I go out to a restaurant?” “How do I plan for travel to a country where they don't speak my language?” There's lots of considerations with layers of complexity, and there are resources out there. And as a medical community, we don't always do the best job of giving families those resources so that they're empowered to keep themselves or their families safe while they live their lives. But the expectation is that children and adults with food allergies live fully healthy, happy lives. So, you need to connect with a doctor who helps you do that.

John Horton:

Those are fabulous words of wisdom, Dr. Bjelac.

Dr. Jaclyn Bjelac:

Thanks.

John Horton:

Before we say goodbye, anything else you'd like to add?

Dr. Jaclyn Bjelac:

No, I think that this has been such a great overview of some common allergens, and just because your allergen isn't on this list doesn't mean that it's not a real allergy. You can be allergic to anything with a protein or, that's what I tell my patients. But managing one or many food allergies, especially many of our kids do, all the concepts are the same, and you are not alone. There are others out there on this journey with you. And if you don't know anyone personally in their lives, many of the patients and families that we serve in the food allergy center have found really powerful connections in the community or even leveraging the internet to just try and share experiences and learn best practices for people who are going through what you're going through.

John Horton:

Well, thank you so much for your time today. As somebody with a child with a food allergy, I can't even begin to tell you how much it means.

Dr. Jaclyn Bjelac:

Thank you so much. It's an honor and a privilege.

John Horton:

Odds are someone in your life has an allergy to one or more of the foods that we discuss today. With more understanding of the condition and a little caution in the kitchen, you can play a part in keeping them safe. Until next time, be well.

Speaker 3:

Thank you for listening to Health Essentials, brought to you by Cleveland Clinic and Cleveland Clinic Children's. To make sure you never miss an episode, subscribe wherever you get your podcasts, or visit clevelandclinic.org/hepodcast. This podcast is for informational purposes only and is not intended to replace the advice of your own physician.