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In the Know - All about...Nut Allergies

By: Mendy Hecht

July 5, 2018

In the Know

All about… nut allergies


Why allergies to nuts are on the rise is a subject worthy of its own article.  But with nut allergies spreading significantly across society in recent years (this editor’s son discovered an unknown allergy to coconut and walnut the hard way), this article will focus on what nut allergies are.  So, here we go!



Most “nut allergies” involve nuts categorized as tree nuts.  But not every “nut” behind allergies grows on a tree.


To preface: Most of the items we call “nuts” grow on trees; hence, for most of them, we use the scientific term “tree nut.”


But the ever-popular peanut, while both a common “nut” and the most common “nut allergy,” is actually a legume (a kind of bean), not a nut and certainly not a tree nut.  It’s a similar situation with the coconut—also a common “nut” but scientifically a fruit, not a nut.


Regardless, both “nuts” can cause serious or even life-threatening reactions in those allergic to them, as do tree nut allergies in those allergic to them.


From almonds, cashews and walnuts to less-popular pine nuts and lichee nuts, tree nuts come in many shapes and sizes.  Along with peanuts, tree nuts are one of the food allergens most often linked to anaphylaxis—a serious, rapid-onset allergic reaction that may be fatal.  A tree nut allergy usually lasts a lifetime; fewer than ten percent of people with this allergy outgrow it.



An allergy to tree nuts is one of the most common food allergies. Along with peanuts, it is also one of the food allergens most frequently linked to anaphylaxis, a potentially life-threatening reaction that impairs breathing and can send the body into shock.


Symptoms of a tree nut allergy include:

·         Abdominal pain, cramps, nausea and vomiting

·         Diarrhea

·         Difficulty swallowing

·         Itching of the mouth, throat, eyes, skin or any other area

·         Nasal congestion or a runny nose

·         Nausea

·         Shortness of breath

·         Anaphylaxis, a potentially life-threatening reaction that impairs breathing and can send the body into shock



Because a tree nut allergy can cause a life-threatening reaction, an accurate diagnosis is essential. Your allergist will start by taking a medical history, asking about any previous allergic reactions and about any family history of allergies. Skin-prick tests and/or blood tests may be used to determine the presence of allergen-specific immunoglobulin E, an antibody that binds to allergens and triggers the release of chemicals that cause symptoms.


If those tests are inconclusive, your allergist may order an oral food challenge. In this test, a patient is fed tiny amounts of the suspected allergy-causing food in increasing doses over a period of time, under strict supervision in an allergist’s office or a food challenge center. Emergency medication and emergency equipment must be on hand during this procedure.



As with most food allergies, the best way to avoid triggering an allergic reaction is to avoid eating the offending item.


People who are diagnosed with an allergy to a specific tree nut may be able to tolerate other tree nuts, but allergists usually advise these patients to avoid all nuts. Tree nuts are often used as garnishes in salads, as an ingredient in Asian dishes, and as an ice cream topping. They may also be found in baking mixes, breading, sauces, desserts and baked goods.


Tree nuts are among the eight most common food allergens affecting adults and children, and are specifically mentioned in the Food Allergen Labeling and Consumer Protection Act (FALCPA) of 2004. This means that the presence of these items must be highlighted, in clear language, on ingredient lists. Some companies may voluntarily include information that their food products that don’t contain nuts were manufactured in a facility that also processes nuts, though such a statement is not required by law. It is important for people with tree nut allergies to read labels carefully.


Some alcoholic beverages may contain nuts or nut flavoring added in the distillation process. Most alcoholic beverages aren’t covered by the FALCPA requirements; if “natural flavors” or “botanicals” are cited as an ingredient, you may need to call the manufacturer to determine whether that indicates the presence of nuts or nut flavoring.


Tree nut oils, which may contain nut protein, can be found in lotions, hair care products and soaps; those allergic to tree nuts should avoid using these products.


What to watch out for

Even a little bit that you swallow or inhale could cause an allergic reaction. You know to avoid the obvious foods, such as almond butter, cookies with walnuts baked in, or oatmeal studded with pistachios.


But other trigger foods, including sauces and gravies, are more surprising.


You need to know what to look for, so you can check before you buy or use a product.

Peanuts and tree nuts aren’t the same. But if you’re allergic to one, you may also need to avoid the other. Ask your doctor to be sure.


Tree nuts include:

·         Almonds

·         Brazil nuts

·         Cashews

·         Chestnuts

·         Filberts

·         Hazelnuts

·         Hickory nuts

·         Macadamia nuts

·         Pecans

·         Pine nuts

·         Pistachios

·         Walnuts


Check these foods for nuts

You may find peanuts or tree nuts in things like these:

·         Baked goods. Cookies, candy, pastries, pie crusts, and others

·         Candy. Chocolate candy especially; also nougat and marzipan

·         Other sweets. Ice cream, frozen desserts, puddings, and hot chocolate

·         Cereals and granola

·         Trail mix

·         Chili and soups. Peanuts or peanut butter are sometimes used as thickeners.

·         Grain breads

·         High-energy bars

·         Honey

·         International foods. Nuts are common ingredients in African and Asian cooking (especially Thai and Indian); also in Mexican and Mediterranean foods.

·         Veggie burgers

·         Sauces. These may include barbeque sauce, hot sauce, pesto, gravy, mole sauce, glazes, or marinades.

·         Salads and salad dressing


Avoid these items

·         Nix them when you cook, and look for them on food labels:

·         Nut butters. Almond, cashew, peanut, and others

·         Nut pastes. Includes products like marzipan, almond paste, and nougat

·         Nut oils. Includes cold-pressed or expressed peanut oil, and others

·         Hydrolyzed plant or vegetable protein. These can have peanuts in them.

·         Peanut flour

·         Nut extracts, like almond extract


Four tips for avoiding nuts

1. Ask your server.  Foods that don't contain peanuts or tree nuts can get contaminated if they’re made in the same place or with the same equipment. It can also happen in restaurants that use lots of ingredients, and even in ice cream parlors if scoops or other equipment are shared.

2. Check the label each time you buy a product. Food makers sometimes change the recipe.

3. Look outside the kitchen. Nuts can also be in lotions, shampoos, and pet food. Check labels before you buy or use them.

4. Carry an epinephrine auto-injector. Carry two with you at all times, and know how to inject it. For some people, an allergic reaction to nuts can become life-threatening, so always be prepared.



There's no definitive treatment for allergy, but researchers continue to study desensitization.  Oral immunotherapy (desensitization) involves giving children with allergies, or those at risk for allergies, increasing doses of food containing nuts over time. However, the long-term safety of oral immunotherapy for allergy is still uncertain, and this treatment is not yet FDA approved.


New research suggests that desensitizing at-risk children to peanuts between ages 4 and 11 months may be effective at preventing peanut allergy. Check with your doctor because there are significant risks of anaphylaxis if early introduction of peanuts is performed incorrectly.


In the meantime, as with any food allergy, treatment involves taking steps to avoid the foods that cause your reaction and knowing how to spot and respond to a severe reaction.


Being prepared for a reaction

The only way to prevent a reaction is to avoid nuts and nut products altogether. But not are common, and despite your best efforts, you're likely to come into contact with them at some point.


For a severe allergic reaction, you may need an emergency injection of epinephrine and to visit the emergency room. Many people with allergies carry an epinephrine autoinjector (EpiPen, Auvi-Q, Twinject). This device is a syringe and concealed needle that injects a single dose of medication when pressed against your thigh.


Know how to use your autoinjector

If your doctor has prescribed an epinephrine autoinjector:

·         Carry it with you at all times. It may be a good idea to keep an extra autoinjector in your car and in your desk at work.

·         Always replace it before its expiration date. Out-of-date epinephrine may not work properly.

·         Ask your doctor to prescribe a backup autoinjector. If you misplace one, you'll have a spare.

·         Know how to operate it. Ask your doctor to show you. Also, make sure the people closest to you know how to use it — if someone with you can give you a shot, he or she could save your life.

·         Know when to use it. Talk to your doctor about how to recognize when you need a shot. However, if you're not sure whether you need a shot, it's usually better to go ahead and use the emergency epinephrine.


Lifestyle and home remedies

One of the keys to preventing an allergic reaction is knowing how to avoid the food that causes your symptoms. Follow these steps:

·         Never assume a food doesn't contain peanuts. Peanuts may be in foods that you had no idea contained them. Always read labels on manufactured foods to make sure they don't contain peanuts or peanut products. Manufactured foods are required to clearly state whether foods contain any peanuts and if they were produced in factories that also process peanuts.  Even if you think you know what's in a food, check the label. Ingredients may change.

·         Don't ignore a label that says a food was produced in a factory that processes peanuts. Most people with a peanut allergy need to avoid all products that could contain even trace amounts of peanuts.

·         When in doubt, say “no thanks.”  At restaurants and social gatherings, you're always taking a risk that you might accidentally eat peanuts.  Many people don’t understand the seriousness of an allergic food reaction, and may not realize that a tiny amount of a food can cause a severe reaction.  If you are at all worried that a food may contain something you're allergic to, don't try it.