About one in 260 people in the United States has a coconut allergy
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Key takeaways:
- 0.39% of the general population, including 0.22% of children and 0.43% of adults, have a coconut allergy.
- 40.1% of those with a convincing coconut allergy have an epinephrine prescription.
Approximately one in 260 people in the United States reported symptoms consistent with an IgE-mediated coconut allergy, according to a study published in Annals of Allergy, Asthma & Immunology.
However, fewer than half of these people reported that their allergy was confirmed by a physician, Shruti Sehgal, MD(Hom), MS, senior research data analyst, Center for Food Allergy and Asthma Research, Northwestern University Feinberg School of Medicine, and colleagues wrote.
“Despite the labeling requirement by the Food Allergen Labeling and Consumer Protection Act (FALCPA) for products containing coconut, little epidemiologic data are available estimating the burden of coconut allergy in the United States,” Sehgal told Healio.
Prevalence, patient characteristics
The researchers surveyed 51,819 households in the United States, including self-reports for 40,443 adults and caregiver-proxy responses for 38,408 children, between Oct. 1, 2015, and Sept. 30, 2016.
“An estimated 0.73% of the U.S. population reported a coconut allergy,” Sehgal said.
Specific findings indicated that 0.39% (95% CI, 0.33%-0.45%) of the general population had a convincing coconut allergy with at least one stringent symptom.
These responses also included 0.18% who reported a physician-diagnosed convincing coconut allergy, or 0.22% (95% CI, 0.16%-0.3%) of children and 0.43% (95% CI, 0.37%-0.51%) of adults.
“Our study findings indicate that, despite its apparently lower prevalence relative to other major food allergens, coconut allergy nevertheless impacts a substantial number of Americans,” Sehgal said.
Also, 0.47% (95% CI, 0.37%-0.59%) of children and 0.81% (95% CI, 0.72%-0.91%) of adults reported a current coconut allergy without reaction symptoms consistent with established criteria for convincing, IgE-mediated food allergy, but the researchers did not include them in their overall estimates of convincing coconut allergy.
The survey also found that 0.12% (95% CI, 0.08%-0.18%) of children and 0.2% (95% CI, 0.16%-0.24%) of adults had a coconut allergy that was diagnosed by a physician with an oral food challenge, skin prick test or specific IgE test.
The respondents with convincing coconut allergy were 55.4% female, whereas the general population was 51.1% female. Additionally, 56.4% of the respondents with convincing coconut allergy and 62.2% of the overall population reported non-Hispanic white race and ethnicity.
Annual household incomes among respondents with food allergy included 24.4% at less than $25,000, 25.2% between $25,000 and $49,000 and 27.5% between $50,000 and $99,999, which the researchers called similar to the general population.
Compared with the general population, the researchers continued, people with coconut allergy were more likely to report public health insurance (37.8%) or no health insurance coverage (24.1%).
Similarly, the researchers said, coconut allergy was over-represented among households with the lowest level of educational attainment (7.3%) compared with the general population (4.5%).
Comorbidities, symptoms
Comorbid atopic conditions were more prevalent among respondents with coconut allergy compared with the general population as well. For example, 30.3% of those with coconut allergy and 12.2% of those in the general population had asthma (P < .001).
These higher rates also included eczema (10.9% vs. 6.5%; P < .02), eosinophilic esophagitis (1.8% vs. 0.2%; P < .001) and food protein-induced enterocolitis syndrome (2.6% vs. 0.3%; P < .001).
Reactions to coconut also included multiple organ involvement for 47.5% of respondents with convincing coconut allergy as well as severe reactions such as coconut-induced wheeze, fainting, dizziness and/or low blood pressure for 16.1%.
Among the 69.8% of respondents with coconut allergy and at least one other convincing food allergy, 27.8% had a peanut allergy and 20% had an allergy to one or more tree nuts.
Also, 57.3% were allergic to one or more of the top eight food allergens, and 69.8% had an allergy to any other food, including but not limited to the top eight.
The survey found that 40.1% of respondents with a coconut allergy had a current epinephrine prescription, and 59.3% had visited an ED at least once in their lifetime because of a food allergy reaction.
Additional findings included 46.2% who met the established criteria for a convincing coconut allergy and had a physician diagnosis too, including 73.2% diagnosed with SPT, 28.1% with coconut sIgE blood tests and 20.2% with OFC.
Children with a convincing mono-coconut allergy had a mean six-item Food Allergy Independent Measure (FAIM) score of 2.51 (standard error [SE], 0.28), and those with reported mono-coconut allergy had a mean FAIM score of 3.06 (SE, 0.28), with higher scores on the seven-point scale indicating greater psychosocial burden related to food allergy.
Mean FAIM scores for children and adults with convincing mono-coconut allergy were comparable with mean FAIM scores among children and adults with egg and milk allergy but lower than mean FAIM scores among children and adults with peanut allergy as well.
Finally, 24.8% of the respondents with a history of convincing coconut allergy reported outgrowing their allergy, including 31.8% of children and 23.7% of adults.
Conclusions, next steps
Despite its lower prevalence, severity and psychosocial impact compared with other food allergies, the researchers said that coconut allergy affects a substantial number of Americans.
“To our knowledge, this is the first study to provide insights into the population-level burden of coconut allergy among U.S. children and adults,” Sehgal said.
Given the increasing coconut consumption and use in the U.S., she continued, issues around labeling of coconut-containing products will probably become more important.
“As such, the present findings provide much needed context regarding the U.S. population-level prevalence, severity, distribution and burden of coconut allergy,” Sehgal said.
Also, with nearly two in five individuals with coconut allergy reporting a current prescription for an epinephrine autoinjector and one in five using an autoinjector to treat a reaction for coconut allergy, she continued, coconut allergy management practices remain suboptimal.
“Although coconut may be more easily avoided than other, more ubiquitous allergens, it is important to be aware of the allergenic potential of coconut and targeted clinical testing can lead to a precise diagnosis,” Sehgal said.
The researchers, then, encouraged individuals who believe they may have an allergy to seek targeted clinical testing, which can lead to a precise diagnosis and prevent unnecessary food avoidance and poor quality of life.
Also, Sehgal said, these epidemiologic estimates provide context to coconut allergy stakeholders to address the public health burden of food allergies in general.
“Future studies will be needed to further define the predictive values of coconut skin prick testing and sIgE against the reference standard of food challenge,” she said.
For more information:
Shruti Sehgal, MD(Hom), MS, can be reached at shruti.sehgal@northwestern.edu.
Perspective
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There has not been great data on the prevalence of coconut allergies in the U.S., so these findings are definitely significant, especially because those with reported coconut allergies were also more likely to report atopic conditions such as eczema and asthma. There also seems to be a causal link between other food allergies (especially peanuts, tree nuts and the big eight) and the prevalence of coconut allergies based on these data.
With one in 260 Americans reporting food allergy symptoms after eating coconut, these findings could prompt more comprehensive food labeling and awareness, especially since coconut is categorized as a tree nut by the FDA, yet many are unaware of this.
In my experience as a dietitian, I do not often see diagnosed coconut allergies, but I do see patients who have more than one food allergy and complain of uncomfortable reactions to eating certain tropical fruits such as coconut. These findings highlight why it is so important for us to know the prevalence of coconut allergies to get our patients the care they need to understand their allergies more comprehensively.
The biggest takeaway from this study I see is that coconut allergies are more common among individuals who have existing food allergies or atopic conditions. Doctors can leverage this knowledge for their patients and make sure these individuals in particular are getting tested for a coconut allergy, especially if they are still dealing with unexplained symptoms. If doctors are also more aware that one in 260 Americans report allergic reactions to coconut, they may be more likely to refer certain patients to a board-certified allergist for further testing.
Due to some of the limitations of this study, I would like further research done on this topic that utilizes confirmatory testing on a smaller but more well-controlled sample size. This is often less practical but a more accurate representation of true allergies, as surveys may overestimate allergy prevalence.
Perspective
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There have been quite a few conversations over the past year of allergists seeing an increase in coconut allergies, but this was all anecdotal. It is nice to have some real evidence of this issue so that we can get into management and prevention. The authors note that there has been an increasing trend of using coconut oil in skin and hair care, which may be contributing to sensitization.
Most patients start with their primary care physician when they suspect an allergy or are experiencing allergic symptoms. Atypical allergies may be less likely to be immediately recognized as a possible IgE-mediated allergy. These data really highlight the importance of exploring potential food triggers outside of the typical top nine allergens.
More evidence is pointing to a healthy skin barrier as important to the prevention of food allergies. Making sure patients understand what products are beneficial for their skin and what products may be causing problems is going to be important moving forward. This is likely to be an uphill battle, since so many people on popular and social media really push these natural, often food-based, moisturizers such as coconut oil.
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