Ann Allergy Asthma Immunol 129 (2022) 391−392
Contents lists available at ScienceDirect
Editorial
Defining socioeconomic and racial disparities in food allergy
The time is now
The Annals’ 2022 food allergy theme issue focuses on health dis-
parities in food allergy, with 4 review articles providing important
insight into factors contributing to health inequities and potential
steps toward closing identified gaps (Fig 1).
Food allergy is both a medical and public health issue, and we are
just beginning to understand the underlying social determinants that
govern food allergy outcomes. In contrast to other allergic diseases
such as asthma and atopic dermatitis, in which socioeconomic factors
have been identified as playing a major role, food allergy remains sig-
nificantly understudied. Warren et al1 ground the conversation in
historical context, noting that data looking at health differences
across groups with food allergy have typically evaluated race and
ethnicity rather than other factors such as household income or edu-
cational attainment. However, studies reveal that minority race and
socioeconomic status are associated with lower rates of formal food
allergy diagnosis and lower rates of epinephrine prescription but
higher rates of food-induced anaphylaxis.2 Outside of disease-specific
differences, environmental conditions associated with lower socio-
economic status can affect general access to health care and food
security, housing, and safety.3 Effective reduction of food allergy bur-
den require mitigating larger structural problems, including poverty
and racism.
Food security is of paramount importance when dealing with food
allergy, but food insecurity (a “household-level economic and social
condition of limited or uncertain access to food”4) has increased
nationally. One report evaluating the impact of coronavirus on food
insecurity estimated that as many as 1 in 4 US children lives in a
household experiencing food insecurity.5 Those with food allergy
should have consistent access to safe foods, yet studies have identi-
fied disparities in access on the basis of race and socioeconomic sta-
tus.2 Scurlock et al6 suggested that screening for food insecurity in
clinical settings should become common practice, helping to reduce
stigma, identify vulnerable populations, and connect those affected
with community resources. In terms of community resources, there
are notable federal nutrition and food assistance programs, and non-
profit and voluntary civic groups, which help families mitigate hun-
ger. However, allergen-free foods can be in limited supply and at
high cost in these food retailers, pantries, and banks.6 More impor-
tantly, Bartnikas et al3 also called attention to the fact that families at
risk of food insecurity perceive the risk of accidental exposure to be
higher and have an overall worse quality of life as compared with
their food secure counterparts.
As pointed out by Stephen et al,7 most food allergic individuals are
diagnosed in childhood, making the school environment a
Disclosures: The authors have no conflicts of interest to report.
Funding: The authors have no funding sources to report.
https://doi.org/10.1016/j.anai.2022.07.018
1081-1206/© 2022 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.
particularly important context in which to evaluate risk factors, cur-
rent practices, and potential solutions. Stephen et al7 and Bartnikas et
al3 pointed out that schools should have undesignated stock epineph-
rine autoinjectors readily available, and accessible staff who can
effectively identify food-induced allergic reactions and administer
appropriate treatments. Shah et al8 provided strong evidence to sup-
port universally stocking epinephrine in schools as a priority initia-
tive, reporting that students in schools with higher socioeconomic
status are 6 times more likely to have student-assigned epinephrine
autoinjectors than those in lower socioeconomic status schools. How-
ever, Bartnikas et al3 highlighted that, currently, many inner-city
schools struggle with limited funding and resources, increased stu-
dent-teacher ratios, lack of access to full-time nurses, and bureau-
cratic challenges, making a universal approach to school readiness
challenging. They suggested that approaches to school policies need
to be flexible and tailored, depending on the unique circumstances of
individual school settings, with particular attention to the most
underserved and vulnerable communities.3
Looking toward the future of food allergy diagnostics and thera-
peutics, disparities exist in the setting of clinical trials and emerg-
ing therapies as well. Warren et al1 underscored that, in general,
clinical trials do not recruit, enroll, and retain participants who
“reflect the underlying heterogeneity on the affected population.”
They provide the example of Palforzia, for which the phase 3 trial
included 9 non-Hispanic Black participants among the intention-
to-treat population of 551. It is unknown whether this lack of
representation is caused by investigators’ bias or whether it reflects
other barriers to access. However, future clinical trials in food
allergy would benefit from concerted efforts to recruit and enroll
diverse patient populations. Warren et al1 continued to suggest
that immunotherapies for food allergies are expensive once
approved and available, and disparities in access will continue and
worsen unless equitable access to cost-effective food allergen
immunotherapies is prioritized.
We hope that this 2022 Annals theme issue presents powerful
commentary on the factors contributing to health disparities in food
allergy (Fig 1). There is a need for more research around this impor-
tant topic, given that discussions are often extrapolated from more
general work on racial and ethnic minorities and socioeconomically
disadvantaged populations.3 In addition, the expression of allergic
disease is strongly influenced by environmental factors and social
determinants of health, and these associations have not been well
studied in food allergy as compared with other atopic diseases such
as asthma and atopic dermatitis. The review articles within this issue
highlight the need for increased focus, both on an individual and sys-
tematic level, on ways in which to fundamentally reduce and elimi-
nate health disparities in food allergy.
392 Editorial / Ann Allergy Asthma Immunol 129 (2022) 391−392

Figure 1. An overivew of the diverse factors contributing to disparities in food allergy. WIC, women, infants, children program.

Stephanie Leeds, MD*
Anna Nowak-Wegrzyn, MD, PhDy,z
* Yale School of Medicine
New Haven, Connecticut
y Addressing disparities and improving management. Ann Allergy Asthma Immunol.
Department of Pediatrics, Hassenfeld Children’s Hospital
NYU R. Grossman School of Medicine
New York, New York
z 5. Feeding America. The impact of coronavirus on feed insecurity in 2020. 2020. https://www.
Department of Pediatrics, Gastroenterology and Nutrition, Collegium
Medicum
University of Warmia and Mazury
Olsztyn, Polan
anna.nowak-wegrzyn@nyulangone.org
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