If you’re a parent, you’ll be familiar with the “nut-free” business. This note came home from our four-year-old’s nursery: “Jack’s snack bar had nuts in it today. Please can you make sure he doesn’t have nuts in his snack because we have children with nut allergies.” The culprit? A cereal bar. Can it really have nuts in it? How did I not notice?
I check the ingredients. “For allergens, including cereals containing gluten, see ingredients in BOLD.” Ah, here it is in BOLD. “Chopped ALMONDS (0.5%).” It is the last in a list of 15 ingredients. How dangerous would this amount be to a child with an allergy if they sat next to another child eating it?
It’s the backdrop to every school trip, every bake sale, a lot of playdates. I am not (exactly) complaining about this: allergic reactions can be life-threatening. But I merely note a thing I witnessed recently. On the tombola at the school fair, I saw a mother reduced to tears of frustration as she had to unwrap every single one of several hundreds packs of pre-wrapped “lucky dip” sweets when it emerged that someone had contaminated the supply with some Snickers from a Celebrations pack. “Is this really necessary?” I asked. “The Snickers are wrapped. If a child with an allergy got that sweet, they’d know not to unwrap it.” “It’s not worth the risk,” came the reply. “In any case, we can’t have them on the premises. This is a nut-free school.” The school’s policy is simple, and not uncommon: no nuts on the premises in any shape or form. It’s not worth the risk.
Fear and anxiety are no longer confined to nuts nor to the school environment. It is not unusual for parents to pass you an EpiPen as they hand over their child at a playdate, as if you should feel comfortable administering such a thing when you are clueless. In the past six months my brother-in-law and my mother have been diagnosed as coeliac. He misses malt vinegar. She misses normal bread. According to the NHS, rates of food allergies have risen sharply in the last 20 years. There has also been a fourfold increase in coeliac diagnosis between 1990 and 2011. Allergies and intolerances are everywhere. Even if you don’t have any yourself, it can feel as if you might be about to develop one or perhaps you ought to, in order to be sociable.
The situation is becoming unmanageable, says nutrition therapist Ian Marber. “A fairly large percentage of people who avoid gluten don’t actually know what gluten is.” It’s a protein found in wheat, barley and other grains. “It’s about the use of language,” he says, “In the same way that ‘allergies’ and ‘intolerances’ have become interchangeable in people’s minds, so have wheat and gluten. The shorthand version is that “gluten-intolerant” enters the national psyche and becomes a condition. Maybe I’m not the best person to talk to about it because I have coeliac disease. Years of misery and a biopsy before it was diagnosed. And now it’s a lifestyle choice.” He laughs, while acknowledging that he does not find any of this funny at all.
For some, a form of souped-up intolerance is a lifestyle choice. According to Mintel, four out of five of those who eat food specifically marketed as “gluten-free” have not been diagnoses with coeliac disease (1% of the population are gluten-intolerant). None of this should be confused with allergies: milk and egg allergies are described as “common in young children” and according to the NHS, at least one in 14 children has at least one allergy.
The situation has been further complicated by a recent report from King’s College London’s Department of Paediatric Allergy which suggests very young children who risked developing a peanut allergy could be helped by “repeatedly exposing” their immune system, “from an early age to peanut”. This contradicts previous advice. It’s all very confusing.
“Some of the anxiety around this topic is misplaced,” says Dr Adam Fox, consultant paediatric allergist at Guy’s and St Thomas’ Hospitals, “and sometimes there is not enough anxiety and care. We spend all day every day working with children who have life-threatening reactions to food. That’s allergy. It’s not the same as intolerance. That’s middle-aged people feeling a bit better when they don’t eat wheat.”
There is a vast difference between “allergy” and “intolerance” (and even “sensitivity”). “You cannot use that terminology interchangeably,” says Fox, even though these terms seem to have become conflated in people’s minds. “If you ask any population anywhere in the world whether they believe they have an allergy, they will massively over-perceive what is going on. Allergy is a very small speciality and is often misrepresented.”
An allergy is an immediate reaction that occurs directly after consuming a food, even in tiny amounts, and can require urgent medical attention. Allergy is an immune system reaction and can cause swelling, vomiting and, in extreme cases, anaphylactic shock (severe breathing difficulties). Intolerance (or sensitivity) usually takes longer to show up in the body and is affected by volume: you might be able to consume small amounts of that food and be fine. Intolerance is likely to have less serious physical effects: digestive problems, bloating, discomfort, mild cramps.
To complicate matters – since December 2014 the food industry (including restaurants and pubs) has had to comply with new EU regulations. Fourteen allergens, including cereals, eggs, milk, nuts and fish, must be highlighted in the list of ingredients.
Unsurprisingly, intolerance and its faddy cousin “avoidance” are big business. In 2012 “free-from” sales (of gluten- or wheat-free foods) were valued at £228m, an increase of 25% in a year. Gluten-free specialist Genius Foods estimates that 16% of the population buy gluten-free products. A year ago it estimated that “this has the opportunity to double in the next 12 months”. Tesco, Sainsbury’s and Asda all have their own gluten-free ranges with hundreds of products. Pizza Hut and Domino’s have gluten-free options. McDonalds UK has answered questions on this on its website: “Why don’t the UK have gluten-free buns like the Netherlands?” (Answer: different storage and toasting equipment prevents this at the moment.) To give you an idea where this might be going, in the US this market was worth $10bn in 2013 and 30% of Americans now say they want to reduce or eliminate gluten.
Interestingly, in view of how awareness of allergies and intolerances increasingly pervades our consumer lives, the data on this both in the UK and the US are inconclusive, unfinished and small-scale. Allergy specialists say the same thing: there is no rise in incidence but there is a massive rise in reporting and diagnosis. This is true, for example, of gluten intolerance. “It has become more widely diagnosed because of awareness,” says Dr Adrian Morris of the Surrey Allergy Clinic, a consultant for adults and children. “I don’t think there is an increase. It has stayed around 1% of the population. But one in a hundred people – that is still quite common.”
Gluten is a case in point. Around 1% of the population has coeliac disease. This is a genetic autoimmune disease that damages the small intestine and interferes with the absorption of food. The only treatment is a gluten-free diet. In addition to this group, though, there is also non-coeliac gluten sensitivity (NCGS): “If you test on this group, they come back negative [for coeliac disease] but they respond to a low-gluten diet.”
And then, says Morris, “there are the worried well who don’t have problems with gluten but are avoiding it because the media have made gluten into Public Enemy Number One.” He feels for the restaurateurs, he says: “It must be a nightmare for them to have a gluten-free menu.” In his view, around 25% of the population is avoiding gluten when, in reality, sensitivity (or intolerance in the case of those with coeliac disease) affects only around 2-3% of people. “People are definitely over-self-diagnosing,” he adds.
What other dangers are there here? There is no immediate horror in needlessly removing gluten from your diet, but, says Morris: “You need to make sure you’re not cutting out essentials. It’s a good source of vitamin B and protein and carbohydrate.” He adds: “I don’t think it’s healthy to be anxious around food. It’s about everything in moderation. You might be avoiding gluten but having excessive amounts of other foods. You want a balanced diet, not to be cutting out one thing.”
When it comes to children’s diets, parents’ concern is understandable, especially when allergies are common among the under fives. But here’s the interesting bit (from the NHS website): “Most children who have food allergies to milk, eggs, soya and wheat in early life will ‘outgrow’ this allergy by the time they start school. Peanut and tree-nut allergies [walnuts, brazils, almonds, pistachios] are usually more persistent. An estimated four out of five children with peanut allergies remain allergic to peanuts for the rest of their lives.” Also, it says, food allergies that develop during, or persist into, adulthood, are likely to be lifelong.
This is where things have changed in the past few decades. When I was growing up in the 1970s, these people would probably have had unexplained illnesses. But we don’t all have allergies (or intolerances) though and there is no need to behave as if we do. As psychotherapist and healthy eating campaigner Susie Orbach once wrote: “For many of us eating is associated with anguish and abstinence.” Is the awareness of food sensitivities and intolerance a new way of expressing this? Orbach says now: “It’s one thing if you come out in a rash or you exclude a food and your nose stops running. But food intolerances and suggestions of allergies are – for many people – a way to manage their food. It’s ‘troubled eating’ by another name. If they exclude X, Y, Z, they feel safer.”
She does not blame people for this, though: “The food industry makes sure food is not produced as well as it could be. When people take up these things [exclusion diets], they are trying to manage the horror of how food is affecting them on an individual level and how unsafe they are feeling. Food has become something that is not a pleasure but is frightening and makes us fat.”
Allergies and sensitivities can be a new way of labelling this. But it has gone on for decades. Orbach says: “When I wrote Fat Is a Feminist Issue, I met a lot of people who had chosen vegetarianism. It had all the progressive elements in it [as a choice] but it was also this: ‘If I exclude these foods, I’ll be safe. I won’t binge.’ Parcelled inside it is the same terror around what food can do to us because we’ve lost our capacity to control our appetites.”
In families there’s also the risk of children copying our behaviour and our attitudes. So not only is it important to treat allergies and intolerances without being alarmist, but it makes sense to monitor how your own eating comes across in front of your children. Demonising food groups (“I don’t eat carbs”, “I never touch sugar”) encourages children to believe that there are “good” and “bad” foods and that it’s normal to regard food as something that has to be managed as a threat.
The question that most interests Orbach is: “‘What is the problem to which food intolerance is the solution?’ Maybe it’s over-eating. Maybe it’s feeling overwhelmed around food or not feeling able to trust the food industry. Maybe it’s poor health. Is it psychological? Is it political? It can be a combination.”
It often seems to me that we live in a climate where we micro-manage virtually unmanageable things, issuing diktats and warnings. For example, at the school Christmas fair someone shouted at me – as if it were a matter of life and death, which perhaps it is – across the hall: “Are you absolutely sure these [homemade by me] brownies don’t have nuts in them?” Yes, I am sure. On the other hand, though, on a macro level, not all children eat healthily and as a nation we have an obesity crisis. I can’t help feeling that one plays into the other: too much anxiety over things we can’t control and not enough investment in the things we could change. And always – always – fear around food.
Orbach feels sorry for parents. “Parents have a hard job. ‘Don’t eat this. Don’t eat that. Watch out for this intolerance.’ They should be watching what gives their kids stomach aches or rashes. To introduce anything else [such as an awareness of sensitivity or intolerance] is to put more panic on the situation when already there is so much horror around food from the government, the diet industry, the beauty industry, the food industry.”
Meanwhile, self-willed intolerance is growing. Marber says: “I’m often asked to look at a celebrity’s diet, as told to their publicist. It will say: ‘I am allergic to gluten so I am avoiding wheat.’ But then they will eat spelt pasta. That has gluten in it. There was a point when I had a handle on all this. Now there’s no logic to it at all.” Not all the people who are avoiding gluten are doing so because they physically need to. “Some people can’t tolerate garlic. But we don’t have a garlic-free movement suggesting we all give up garlic.”
It’s frustrating, says Dr Fox, that we dismiss allergies but meanwhile suck up urban myths about food intolerances, myths readily consumed by anxious parents. “When talking about allergies, it’s easier to be vague than specific. It’s a nuanced field. For example, allergy symptoms are broad. You eat a peanut and come out in obvious swelling. But we also have delayed allergies, particularly common in infants: eczema, colic, reflux, diarrhoea. All of which are common in children anyway. The tests are unreliable and it’s hard to tease out which child has these symptoms because of an underlying food allergy. The consequence of all this is that people with allergies feel they are not taken seriously enough.”
Meanwhile, in clinic he sees every extreme: “Some parents deal with it in this constant mist of anxiety. Others just deal with it. And some are far too laissez-faire and you get them coming in and saying, “Oh no, we tried him on peanuts again…’”
Only a minority of the population has these problems – 1% will have lifelong food allergies, according to Dr Fox, while 1% are coeliac. A similar percentage may benefit from a gluten- free diet without having coeliac disease. Most people – more than 97-98% – can eat whatever they want with no ill effects. Providing they eat it in moderation. When we focus so heavily on intolerance and “reactions” to food, is that message getting lost?
I always like to ask healthy-seeming people what they eat. And they always say they eat everything. I ask Morris, the allergy specialist who has seen it all. Do you cut anything out? Is there anything you avoid? I’m expecting him to say something like “I avoid dairy” or “I don’t eat processed foods.” Or even: “I love oat cakes.” He replies: “No, no, no. I eat all nice tasty foods.”
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