By Sherry Coleman Collins, MS, RDN, LD and Lauren Highfill Williams
The guidance for preventing peanut allergy is as clear and well-supported as it’s ever been. The 2017 Addendum Guidelines from the National Institute of Allergy and Infectious Diseases (NIAID) recommends introducing peanut foods as early as four to six months to help prevent a peanut allergy. And, for the first time ever, recommendations from the U.S. Dietary Guidelines for Americans Committee include introducing peanut and other common food allergens within the first year of life.
Additionally, children with peanut allergy have the first ever FDA-approved treatment available, Palforzia. In January, oral immunotherapy (OIT) was approved to help prevent life-threatening reactions to peanut due to accidental exposure. It is not a cure but offers improved quality of life for many families.
The evidence-based guidance, recommendations and treatments did not happen overnight. The 20-year journey to where we are today with peanut allergy prevention and treatment is one of compassion, bravery, innovation, and a bit of luck.
The Early Days of the Food Allergy Epidemic
In the late 1990s, the rate of food allergy diagnoses was skyrocketing. No one knew exactly why, but pediatricians and new parents were desperate for action to change the trajectory. In 2000, the American Academy of Pediatrics (AAP) issued recommendations based on the best expert opinion at the time: Delay the introduction of peanut until three years of age—and for other allergens, for one to two years. For children and adults diagnosed with a peanut allergy, the only treatment was for reactions and the advice to prevent a reaction was complete avoidance of the allergen.
Also, in the 90s, many in the peanut industry became increasingly dissatisfied with the peanut quota system and there were calls to eliminate it (which was done in the 2002 Farm Bill). Simultaneously, there was a move in the peanut world to establish a national checkoff program. Tackling the peanut allergy issue head on was a strategic objective. Early board members were convinced that “peanut allergy” was not a passing fad and could become a critical issue to the industry, removing beloved PB&Js from children’s diets and family grocery carts. Board members believed if even one person was harmed by the crop they grew, it was one too many. They were committed to finding solutions for peanut allergy. Furthermore, while peanut was only one of the top eight common allergens, no other commodity board had made a strong commitment to supporting allergy initiatives.
Meanwhile in London, food allergy researcher Dr. Gideon Lack of King’s College was considering the discrepancy between peanut allergy in Israel and the United Kingdom (UK). He learned that Israeli children were often fed a peanut-based teething snack within their first year of life, contrary to guidance from the U.S. and UK at the time. Dr. Lack sought to conduct a comparative study of thousands of genetically similar children in the UK and Israel to determine the cause of the difference in peanut allergy prevalence.
For NPB board member Dee Dee Darden of Virginia, peanut allergies were very personal.
At that time some in the industry were reluctant to talk about the peanut allergy issue. “But we embraced it and we went head on,” said Darden. “We never had our head in the sand—we always addressed it. We were involved in Food Allergy Action Network (FAAN) and other meetings. When [inaugural NPB President] Marie [Fenn] was hired, we formed the Scientific Advisory Committee, which was probably one of the best things we've ever done as a board. We got all the scientists together in a forum, including Dr. Lack, so they could communicate one-on-one with each other. That was instrumental.”
NPB provided some of the very first funding to examine the role of early infant feeding to prevent peanut allergies. In 2002, NPB began to support the work of Dr. Gideon Lack and his team to better understand the impact of early feeding and other factors on the development of peanut allergies.
“The NPB generously supported our original research on the Israel UK study, which associated early feeding of peanut foods with lower peanut allergy prevalence. That work led to our subsequent research programs, including the LEAP study,” said Lack.
However, there was insufficient data available at that time to strongly recommend that peanut should be introduced at a specific age (1).
This update from AAP fueled Dr. Lack and NPB to continue to pursue research that would lead to recommendations to proactively introduce peanut to prevent a peanut allergy. The LEAP Study was a breakthrough in researchers’ understanding of the complex interplay between environmental exposure and oral exposure on natural tolerance. “NPB has continued to support us over the past decade with our Clinical Trials Unit,” said Lack.
Dr. Lack’s team has since conducted the LEAP-On Study, a continuation of the LEAP Study, and the separate EAT Study, which looked at the impact of feeding six potentially allergenic foods in infancy. The work of these researchers, at the conclusion of the LEAP Study, resulted in changes in international feeding guidelines to encourage feeding peanut foods to infants starting at ages four to six months to reduce the risk of developing peanut allergies. Their findings continue to help shape our understanding of this critical issue and prevent future cases of food allergies.
NPB was determined to pursue multiple avenues of understanding, preventing, and treating peanut allergies. In the first year of the Board, farmers funded some of the earliest oral immunotherapy (OIT) research conducted in the United States for peanut allergies. This work, by esteemed researchers Drs. Wesley Burks and Stacie Jones, occurred at both University of Arkansas and Duke University. They did the pioneering work of OIT for food allergy in the U.S., and because of that early exploration other researchers and companies have been able to take the OIT concept and bring it to fruition.
“Funding from peanut farmers helped with the framework for OIT,” said Burks, who currently serves as executive dean for the University of North Carolina at Chapel Hill School of Medicine. “The National Peanut Board provided initial funding for a pilot study we conducted on egg OIT. That early support helped leverage additional funding from other organizations to continue and expand OIT research.”
NPB continued its commitment to finding a treatment for peanut allergies with support in 2008, 2009, and 2011 of the important continuation of this work in OIT by Dr. Stacie Jones at University of Arkansas. Early and ongoing support of novel treatments like OIT help researchers lay the groundwork for bigger studies and garner more support from private and public funding sources.
Complementing this work toward treatment, NPB provided some early funding in 2003 for the University of Nebraska Food Allergy Research & Resource Center in their efforts to better quantify threshold doses, which are the minimum amount of peanut protein that causes a reaction in 95-99 percent of peanut allergic individuals. Understanding this minimum threshold has helped OIT researchers determine safer doses at which to begin treatment, among other outcomes.
Recognizing that multiple solutions may be needed for peanut allergies besides OIT, NPB funded other early research on peanut allergy treatment research. In 2001 and 2002, NPB provided funding to help begin research on anti-IgE therapeutics. Partnering with Tanox Inc. (now owned by Roche Holding), researchers worked toward the development of a novel monoclonal antibody to treat peanut allergies. Promising research, this early effort spurred other developments in this area, including for Xolair and future generations of anti-IgE treatments like Omalizumab and other biologics. Although showing potential, these treatments are not available to consumers to treat peanut allergies at this time, as they are still being researched.
The reality is that we still don’t understand many underlying mechanisms contributing to the development of food allergies and reactions. In addition to funding research for treatments, NPB has funded studies to better understand the allergenicity of peanuts, how and why anaphylaxis happens, and how to improve the diagnosis of peanut allergies. Basic research is an important part of moving science forward.
At its seating in 2000, the members of that very first board for the National Peanut Board, recognized their potential to be part of the solution. Darden famously said: “If we’re part of the problem, we want to be part of the solution.” To that end, the National Peanut Board has invested more than $33 million since its inception toward food allergy outreach, education and research.
Darden said, “I think it took a lot of courage for those first Board members to commit to peanut allergy back then, when people didn't want to talk about it. But our board stood together as one. We were in unanimous consent. I think that speaks volumes in the early stages for the board and their dedication to do the right thing.”