Food allergies create obstacles, drive anxiety during airline travel
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Key takeaways:
- 8.5% of respondents reported an allergic reaction during a flight.
- 11.8% were asked to leave a flight or were not allowed on board because of their allergy.
- 98% said food allergy adds anxiety to air travel.
Travel can be stressful enough — especially around the holidays. For families with food allergy, however, the challenges are even harder.
“Quite simply, air travel is something that is top-of-mind for many food allergy patients,” Christopher M. Warren, PhD, director of population health research, Center for Food Allergy & Asthma Research (CFAAR), told Healio.
“But there is little research, particularly in the past 10 years, that has sought to systematically understand the experiences and attitudes of food allergy patients and their families as they relate to air travel,” he continued.
Warren said this is important since solutions to support patients and families cannot be developed without understanding their current challenges and the types of supports that they believe will be most helpful.
Located at the Northwestern University Feinberg School of Medicine, CFAAR surveyed 4,704 adults with a food allergy or who had a child with a food allergy about their commercial airline experiences.
Specifically, 30.5% of respondents had a food allergy; 36.3% had a child aged younger than 13 years with a food allergy; 27% had a child aged 13 to 17 years with a food allergy; 21.3% had an adult child with a food allergy; and 4.9% had a partner with a food allergy.
Managing airborne reactions
Based on the survey, 8.5% of respondents reported a history of one or more in-flight reactions, including peanut (3.9%), tree nut (2.4%) and milk (0.6%). Symptoms were cutaneous (87.3%), oropharyngeal (57.8%), respiratory (51.3%), gastrointestinal (29.8%) and cardiovascular (16.8%).
Reactions were treated with antihistamines (60.7%) and epinephrine (15.1%), with 91.7% of epinephrine provided by the respondent, 5% provided by the airline and 3.3% provided by another passenger. Two-thirds of the time, the airline’s epinephrine came in a vial. The other third of the time, it was in an autoinjector.
Upon landing, 30.1% of those who had an allergic reaction were transferred to a hospital or to urgent care. Emergency landings were requested in 15 cases (3.8%), and five emergency landings were granted. Also, 57.4% of respondents said they reported the reaction to the flight crew or to the airline after the fact.
The cohort also included 93.5% who brought an epinephrine autoinjector on board and 74.9% who carried additional epinephrine. Plus, 81.9% brought antiseptic wipes on board with them, and 82.1% tried to bring their own allergy-safe food on board.
Those who tried to bring their own food included 40.2% who said their food was inspected by airport security or customs, of which 67.9% who said these personnel “ruined” their food. Also, 37.8% requested special handling of their food, and 33.3% had their food confiscated.
Prior to the flight, 67.2% contacted the airline about their food allergy. Respondents also included 11.9% who said they were asked for a doctor’s note confirming their food allergy and 91% who said they had a note ready.
Additionally, 15.6% said airport security asked to see their epinephrine autoinjector and 1.1% said they had their autoinjector confiscated. Further, 11.8% said they had been asked to leave a flight or were not allowed to board because of an issue related to their food allergy.
Among the 4.8% who said the airline asked them to sign a waiver absolving it of liability, including 1.1% who were asked on multiple occasions, 53.7% signed a waiver once and 17.9% signed on multiple occasions.
Customer service
“Another remarkable finding from this survey is what appears to be a concerning trend where those with food allergies are choosing not to disclose their food allergy to airline staff because they see it as potentially more likely to lead to inconvenience or unwanted intervention vs. a helpful, informed effort to facilitate their chronic disease management,” Warren said.
The cohort included 15.8% who said they deliberately do not disclose their food allergy during air travel some of the time, 9% who did so most of the time and 5.7% who did so all the time.
Respondents chose not to disclose their allergy most often because they were concerned that they would get in trouble (13.5%) or that doing so would have led to unwelcomed accommodation (11.9%).
“This is obviously not an ideal context for effective food allergy management, which can require that others take steps to mitigate risk of accidental allergen exposure as well as to promptly identify and treat suspected anaphylaxis, each of which can be rendered more challenging when patients fly under the radar,” Warren said.
Also, respondents had a variety of requests for accommodations that airlines provided as promised, including opportunities to preboard (35.6%), cabin announcements and public service announcements about food allergy (28.8%), allergen-free snacks and meals (22.9%) and buffer zones (20.7%).
“Unfortunately, our survey also identified ways that many current airline policies and practices appear to be suboptimal in supporting travelers managing food allergy,” Warren said.
The most common requests that airlines failed to accommodate despite assurances that they would do so included cabin announcements and public service announcements related to food allergy (20.4%), allergen-free snacks and meals (18.3%), buffer zones (17.4%) and opportunities to preboard (12.9%).
Among the 35.6% who said they had experienced unprofessional or insensitive behavior from airline staff about their food allergy, 76.1% said those experiences impacted how they fly. On the other hand, 32% said that a member of the airline or flight crew went above and beyond to accommodate their food allergy.
When asked if being treated well would make them more likely to choose an airline over others, 21.9% said positive treatment would make them slightly more likely to choose the airline, and 73.7% said it would make them a lot more likely to choose the airline.
Specific factors related to food allergy also were very or extremely important determinants in their air travel decisions, compared with the proximity of the airport to their home, the time and duration of the flight, and other logistical factors.
Anxiety
“One very clear finding of our study is that 98% of our nearly 5,000 respondents declared that having a food allergy added anxiety to the air travel experience,” Warren said.
Levels of anxiety ranged from a little (10%) to some (24.2%) and a lot (63.3%).
“As such, we were unsurprised to learn that respondents found food allergy-related concerns were a major determinant of travel-related decision-making,” Warren noted.
But 97.6% said there would be less anxiety if airlines implemented better policies or provided the right accommodations, including 8% who said it would decrease a little, 22.1% who said the decrease would be moderate and 61.7% who said it would decrease by a lot.
Finally, 22.1% said that they do not travel at all because of their food allergy, 16.4% said their food allergy has a little impact on whether they travel, 21.9% said it impacts their travel somewhat, 19.5% said it impacts travel a lot and 20% said it has an extreme impact on whether they travel.
The size of the impact that food allergy has on how respondents travel ranged from not at all (18.4%) to a little (13.8%), somewhat (24.7%), a lot (21.8%) and extreme (21.3%).
Recommendations
Warren said that these findings have many notable implications, such as the need for more coordinated efforts to support patients and families traveling with food allergy.
“They also show that these air travel experiences appear remarkably similar across the numerous global regions surveyed in the current study of nearly 5,000 individuals from North America, Europe and Australasia,” he said.
Also, Warren said these findings indicate that allergic reactions not only happen on airlines but that they often are unreported to the flight crew or to the airlines, suggesting that these events are not being fully and reliably captured by current reporting systems.
“Finally, these findings also highlight basic, specific steps that can be taken by health care providers and other food allergy advocates that can potentially improve the air travel experiences, and corresponding quality of life, of the large and growing group of patients and families managing food allergy,” Warren said.
The researchers encouraged allergy providers to inform their patients that they can provide a letter or note confirming their diagnosis and specifying their need for epinephrine autoinjectors, allergen-safe food and other accommodations that are reasonable.
Noting that families may not be aware that they can request these accommodations, the researchers said providers should have proactive discussions with them about airline travel and about how they can help.
“Have an honest, evidence-based discussion about the patient and family’s concerns about specific risks while traveling — eg, exposure to allergen residue on seats, exposure to airborne allergens, how to identify and manage anaphylaxis in flight — so that the patient/caregiver can make a more informed decision about their air travel and employ relevant risk mitigation measures,” Warren said.
Physicians also should advise patients and families to do their own research on each airline’s current food allergy policy, Warren suggested.
“Once they are provided with a stated policy, for example, during the booking process, to make a hard copy or PDF of the policy so they can show it to the flight crew,” he said.
Further, Warren said physicians should advise patients about the importance of keeping medications renewed and carrying them in original packaging with their name on it.
Physicians should inform patients and families TSA Cares, Warren said. As individuals with a medical condition, they are potentially eligible for this tailored TSA screening process, which is designed to be more sensitive to medical needs, he said.
Also, the researchers said airlines should honor any reasonable accommodations that have been promised in advance. These accommodations include allowing those with food allergy to preboard the flight so they can clean the space around their seat, as well as stocking epinephrine autoinjectors on every flight and routinely checking them for expiration.
With these findings indicating how seriously that patients and families with food allergies consider accommodations in their travel plans, the researchers advised airlines to provide clear and consistent communication and implementation of policies related to food allergy to ensure positive experiences and outcomes.
Reference:
- Flying with food allergies: ‘A game of roulette’ at 30,000 feet. https://news.northwestern.edu/stories/2024/11/food-allergy-anxiety-at-30000-feet/. Published Dec. 5, 2024. Accessed Dec. 6, 2024.
For more information:
Christopher M. Warren, PhD, can be reached at christopher.warren@northwestern.edu.
Perspective
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This study is important, as an updated review of experiences relating to traveling with food allergies was needed. What’s more, the comprehensive data exploring attitudes, barriers and other factors helps us better understand the specific challenges and stressors people managing food allergies have while trying to stay safe during air travel so that they can be addressed via legislative efforts and patient education. It was great to see that most participants were engaging in important food allergy management strategies, such as bringing epinephrine autoinjectors onboard, eating their own meals, and wiping surfaces down.
With that said, while much of this study didn’t surprise me, it made me sad due to the variety of negative experiences and challenges people reported. Combined with the data highlighting the lack of food allergy-related support felt throughout the air travel process, it was disappointing to see that only 57.4% of participants said they informed airline crew about their allergic reaction or reported it to the airline after the fact.
This seems to illustrate that people worry about negative repercussions, and that there’s a lack of comfort or belief that they’ll receive support from airlines when they inform crew about allergic reactions, which is a major concern for many reasons. It also didn’t surprise me that inconsistent food allergy-related policies and lack of follow through with accommodations led participants to report high levels of anxiety while traveling since unpredictability and uncertainty are common anxiety triggers, especially when managing food allergies.
I’m hopeful that these comprehensive data lead to a multitiered approach to better address the airline travel needs of those managing food allergies.
As a food allergy-informed licensed therapist, my goal is to help families managing food allergies find a workable balance between allergy-related anxiety and living fully. Even with allergic disease diagnoses, I want people to live their best lives, and engaging in air travel might be part of that equation.
Ideally, there would be consistent implementation of food allergy-related policies in the airline industry to help people with food allergies understand the safety expectations and procedures while engaging in air travel. This alone would help decrease anxiety and stress levels.
Yet, until this happens, people with food allergies should aim to educate themselves about food allergy safety and air travel and focus on what’s within their control throughout the air travel process. To help do this, they can:
• research the airline’s current food allergy-related protocols and accommodations;prepare and plan ahead, which helps with food allergy safety as well as anxiety management;
• ensure that they have all that they need to stay safe and navigate potential emergencies (eg, safe food, wipes, epinephrine, doctor’s letter, etc);
• discuss risk management and safety concerns with their own allergist, which might include talking about fears of experiencing allergic reactions due to non-ingestion (contact or airborne) and ingestion exposures, as well as reviewing and confirming food allergy management safety protocols;
• become familiar with physical sensations they experience when feeling anxious, since especially when doing something new or outside of their comfort zone (such as traveling via air), understanding how anxiety shows up in their own body can help them decipher between anxiety and a potential allergic reaction while onboard;
• and identify coping skills that will help them manage your anxiety while traveling, which may include breathing exercises, thought challenging, distraction gadgets, motivational reminders, empowering self-talk and utilizing self-advocacy skills.
Doctors also can help address anxiety about food allergies and air travel:
• Include topics related to risk management during travel in key patient education discussions to encourage patients to discuss anxiety about travel so that they can receive evidence-based and practical guidance for how to stay safe while traveling.
• Alternatively, proactively ask patients if they have upcoming trips or any specific questions or concerns about food allergy management while traveling in order to help them plan and prepare for travel rather than avoid it out of fear.
• Provide a letter for patients to utilize when needed during the air travel process to help explain their diagnosis and the important safety protocols being taken.
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