House of Lords - Science and Technology

Select Committee on Science and Technology Sixth Report

CHAPTER 6: Public Advice and Information

6.1.In Chapter 4, we discussed the burdens of allergic conditions which can touch upon virtually every aspect of daily life. People with a confirmed allergy have to make important decisions when buying food, eating out, purchasing cosmetics or managing their environment. Others face decisions such as what to eat during pregnancy to decrease the chance of an allergic disease developing in the child. This Chapter looks at the range of information available to the general public, examines who produces it, and assesses the role that Government and charities play in providing this.

Labelling

FOOD

6.2.For food allergic consumers, the decision of whether to buy a product or not can be a matter of life or death; when food is prepacked, the consumer has to rely on the labelling to inform purchasing. Food labelling is an area of EU competence, so United Kingdom legislation implements the relevant EU directives, and the FSA "negotiate[s] on behalf of the UK to ensure that EU legislation in this area addresses the needs of UK consumers and industry" (p 149).

6.3.In 2004, the European directive 2003/89/EC was implemented in England through the Food Labelling (Amendment) (England) (No.2) Regulations 2004, requiring food manufacturers to list 12 specified allergenic foods and their derivatives on product labels, regardless of their level of use.[92] This list comprised cereals containing gluten, crustaceans, eggs, fish, peanuts, soybeans, milk, nuts, celery, mustard, sesame seeds and sulphur dioxides or sulphites (at levels above 10mg/kg or 10mg/l). The directives are constantly being updated: in March 2005 a directive was agreed which temporarily exempted certain ingredients derived from these foods on the basis that they were no longer allergenic, and in 2006 a further directive extended the list of foods to include molluscs and lupin. Enforcement of labelling legislation falls to local authorities. If an allergen is incorrectly labelled, then "the affected food may be withdrawn or recalled and information is provided to enforcement bodies, and is also published on the [Food Standards] Agency's website" (pp 152, 158).

6.4.However, this statutory legislation only regulates the labelling of allergens that are deliberately added to foods, and does not regulate the labelling of allergens that may unintentionally contaminate foods during production. Therefore many manufacturers voluntarily provide advisory information such as "may contain allergen X" (most commonly nuts), "made in a factory that also handles allergen X" or "not suitable for" warnings. The Anaphylaxis Campaign noted that "there is little consistency across the industry in how warnings are presented on food packets" (p 172), and the FSA has found that "many consumers find the variety of phrases used for such labelling confusing, and are concerned that they are overused, and many therefore ignore such warnings" (p 158). For the allergic consumer, the everyday task of buying food can therefore present a minefield of potential risks, and may be very costly and time consuming (p 152).

6.5.Although labelling needs to improve, the root of the problem lies in the actual production of food. Ms Andrea Martinez-Inchausti, Assistant Director of Food Policy at the British Retail Consortium (BRC), commented that a "warning should be the last resort and that is the basis on which our members operate. We strongly believe that a warning should not be a substitute for controls or for good practice … the most important part is to identify where cross-contamination occurs and once that is identified to set up control levels to try to minimise it." A good example of this had been seen within the chocolate industry. Simply by changing the order in which products were produced, so that plain chocolate was made before milk chocolate, manufacturers had "significantly reduced the risk of cross-contamination of milk on the plain chocolate" (Q 405).

6.6.The FSA has recognised that labelling is confusing. Its comprehensive "allergy action plan" is backed up by its strategic plan for 2005-10, which includes a high level objective "to develop appropriate policies and standards to help ensure safety and choice for food allergic and food intolerant consumers" (p 169). In 2006 the Agency produced Guidance on Allergen Management and Consumer Information, in partnership with the Anaphylaxis Campaign, the BRC, the Food and Drink Federation and the Local Authorities Coordinators of Regulatory Services (LACORS). This advises food businesses about possible allergen contamination during the production of prepacked foods, and how to reduce or eliminate these risks, so that advisory warning labels reflect the risk of contamination. To reduce confusion on food product labels, the guidance also advises the use of only two simple phrases: "may contain X" or "not suitable for someone with X allergy."[93]

6.7.The FSA has also provided a grant to the Anaphylaxis Campaign to develop the United Kingdom's "first certification programme to enable food companies to ensure optimum allergen control" which invites the food industry to participate on a voluntary basis (p 172). Mrs Hazel Gowland, who works with the FSA and the Anaphylaxis Campaign to provide allergen training for businesses, highlighted the financial pressures on manufacturers who need to keep production "as cheap and simple as possible," often running production lines "night and day." By contrast, lowering the risks of contamination required "separation, segregation, protection [and] limits (i.e. changes of uniform, controls of air, lots of extra hand washing and so on)," so to minimise contamination, businesses therefore always had to make a "compromise" (Q 448). The British Society for Ecological Medicine suggested that "incentives" should be provided for manufacturers to eliminate peanut contamination (p 223).

6.8.The threshold at which a food allergen triggers a reaction varies from one person to another. However Mrs Sue Hattersley, Head of the Food Allergy Branch at the FSA, told us that "the science at the moment is not yet able to let us set thresholds for the allergens in food." Although it is hard to determine a "safe" level for the majority of the public, Mrs Hattersley told us that the FSA was working with a European consortium on this matter because "we know it is something that does need to be done" (Q 397).

6.9.Furthermore, the EU is currently undertaking a fundamental review of all food labelling to rationalise the current legislation. This might provide an opportunity to improve the labelling of allergens. As part of this process, Miss Gill Fine, Director of Consumer Choice and Dietary Health at the FSA, told us that the FSA would be "consulting with a wide range of groups" to ensure that the information provided for consumers was "clear and easy to understand" (Q 410).

6.10.Vague defensive warnings on labels for consumers with food allergy can lead to dangerous confusion and an unnecessary restriction of choice. We recommend that the Food Standards Agency should ensure the needs of food allergic consumers are clearly recognised during the review of food labelling legislation being undertaken by the European Union.

6.11.As sensitivities to various allergens vary widely, we believe that setting standardised threshold levels for package labelling is potentially dangerous for consumers with allergies. Instead, we recommend that food labels should clearly specify the amount of each allergen listed within the European Union directive, if it is contained within the products, and we endorse the Food Standards Agency's initiative to discourage vague defensive warnings.

COSMETICS AND HYPOALLERGENIC PRODUCTS

6.12.The incidence of allergy to hair dye has increased significantly in the last 10 years, and one clinic recently reported a "doubling in frequency over six years."This allergy is often caused by para-phenylenediamine (PPD), a potent allergen, used in many permanent hair dyes. A recent review commented that "a patient with contact allergy to a hair dye often presents with dermatitis on the face or around the hair line. Severe reactions also occur; some patients have had such gross facial swelling that they have been treated initially for angioedema and some have been admitted to hospital."[94]

6.13.The use of cosmetic chemicals such as PPD is controlled in the United Kingdom by the Cosmetic Products (Safety) Regulations 2004, as amended.[95] In 2003, the European Commission agreed a strategy to establish a list of hair dye substances to be allowed for use and in 2006, the European Commission's Scientific Committee on Consumer Products published a memorandum concerning "the fact that many of currently used hair dye substances are skin sensitisers and … this property may be of concern for the health of consumers."[96] The Commission now plans to extend its assessment "to minimise possible risks of allergic reactions caused by hair dyes."[97]

6.14.There are a host of chemicals used in fragrances and other cosmetics. The consequences of increasing exposure to these allergens are unknown, and Professor Gawkrodger noted that "it is particularly worrying in children's products where children are being exposed now to a lot of fragrances and we do not know what is going to happen in, say, 10 years time" (Q 603).

6.15.For consumers who are already allergic, it is difficult to decide which products are safe to use due to a lack of meaningful terminology used on packaging. In the words of Mrs Cox "the terms 'hypoallergenic' and 'dermatologically tested' for somebody who has an allergic skin disease are hugely misleading, and I can tell you from personal experience that you can put either on atopic skin and react massively" (Q 646). Professor Gawkrodger noted that "there is no regulation of the term 'hypoallergenic'" and that when these products are examined, "I see a whole list of things which I know can cause allergy, so I am rather cynical about the label of 'hypoallergenic'" (Q 645).

6.16.Cosmetic products are often tested on the skin of normal volunteers rather than the extensive animal testing that used to occur; hence the phrase "dermatologically tested." By contrast, the allergenicity of a substance depends on an individual person's response and their tendency to develop allergies. Mr Lewis pointed out that under the general Trade Descriptions Act 1968, "any description of a product by a manufacturer or a vendor must not be false or misleading, and this also applies to labelling." However, he noted that enforcement of this with respect to cosmetics was likely to be difficult as "it is hard to believe that Local Authority Trading Standards Officers are marching around local retailers looking for this" (Q 844).

6.17.We contacted the Advertising Standards Authority (ASA) to ask how the advertisement of these products was regulated. The ASA administers three advertising standards codes, produced by two industry bodies, the Committee of Advertising Practice (CAP) and the Broadcast Committee of Advertising Practice (BCAP). The three standards codes are:

The CAP British Code of Advertising, Sales Promotion and Direct Marketing (which relates to non-broadcast advertisements)
The BCAP TV Advertising Standards Code
The BCAP Radio Advertising Standards Code

For non-broadcast advertising, the ASA enforces the Control of Misleading Advertisements Regulations 1988 (as amended), with the Office of Fair Trading acting "as a legal backstop." For broadcast advertising, the ASA works with Ofcom, which acts as the legal backstop for regulating television and radio advertisements (p 325).

6.18.The Advertising Standards Authority reported that the codes "do not provide specific rules on allergy claims or 'hypoallergenic' and 'dermatologically tested'" as "providing code rules on every conceivable advertising claim would render the Codes un-navigable and cumbersome." However, the codes do include rules regarding the use of misleading advertising, and within the last five years the ASA has received complaints about allergy claims which have led to 24 published adjudications, "of which 19 were upheld fully or in part" (p 326).

6.19.As an example, in November 2006 the ASA published an adjudication regarding an advertisement for a silk-filled duvet, which claimed "because it doesn't actually retain any moisture it means bed bugs can't actually live in here … It's 100 per cent hypo-allergenic." BCAP staff had challenged whether the duvet could actually help asthma and eczema sufferers, and whether it was truly 100 per cent hypoallergenic. The ASA decided that there was no evidence to support these claims and that its hypoallergenic description was therefore misleading. As a result of the complaint being upheld, the ASA concluded that the advertisements "must not be shown again in their present form and the products should not be advertised without adequate substantiation for the claims made" (pp 333-335).

6.20.Other complaints had also been upheld, including complaints against air purifiers which claimed to clear the air of "pollutants, dust mites, cold and flu bugs, fungal spores, pet and animal dander, smoke, moulds" or which could "deactivate airborne mite allergens," as well against a washing machine which claimed to provide "allergy free washing" by minimising the residue of detergent left on clothes (pp 332, 335-336). The Advertising Standards Authority therefore plays an important role in regulating any allergenic claims made in advertising.

6.21.The phrases "hypoallergenic" and "dermatologically tested" are almost meaningless, as they only demonstrate a low potential for the products to be a topical irritant. We recommend that such products should warn those with a tendency to allergy that they may still get a marked reaction to such products.

Eating out with a food allergy

6.22.Most statutory food labelling legislation only applies to prepacked foods, so foods that are sold packaged for direct sale, or those sold loose, are exempt. The Anaphylaxis Campaign noted that "despite a growing awareness of food allergy, deaths are still occurring" and "eating out poses an even higher risk because of the complexities of food production in catering establishments, lack of knowledge among catering staff, food enforcement officers and allergic consumers alike, and the fact that allergic consumers do not have the benefit of an ingredient list to guide them" (pp 172-173). The IFR agreed with this, noting that with regard to industry "allergic consumers are at greatest risk from suffering an allergic reaction whilst eating in a restaurant" (p 288).

6.23.In an attempt to educate catering establishments about the dangers of allergen contamination, the FSA published advice for caterers on its website in 2004. The FSA also aims to produce guidance in autumn 2007 on allergen information for foods that are non-prepacked (p 158). But Dr Ian Leitch, a Chartered Environmental Health Practitioner, felt that allergen management should have a higher profile when caterers are trained, and noted that the lack of training was largely "due to the fact that enforcement officers themselves are on a very steep learning curve" (Q 422).

6.24.Mr Les Bailey, Food Policy Officer at LACORS, added that "local authority food enforcement officers, be they trading standards officers or environmental health officers, visit all 600,000 registered food businesses in the UK on a regular basis." They could therefore draw attention to the guidance and could identify the "situations where cross-contamination may occur" (Q 407).

6.25.However, a recent study of catering establishments in Northern Ireland showed that approximately one in five of the premises "provided meals which could possibly have triggered a fatal reaction in the purchaser," that "most front of house staff did not check the allergen status of the meal with those doing the cooking" and that "most environmental health officers felt that they needed more training in the subject of food allergen control in commercial food premises."[98] Dr Leitch warned that without adequate training everyone had "a false sense of security" (Q 407), and recommended a more practical approach to training enforcement officers "from a workshop perspective" to learn widely about the allergens and about "dealing with the customers as well" (Q 426).

6.26.In response, Mrs Hattersley said that the FSA had ensured that there was "an inclusion of food allergy in the food safety modules" of the national occupational standards for the hospitality sector (Q 423). She also described the FSA's course on allergen management for enforcement officers, which had proved popular, so they were "rolling out more later on in the next financial year" (Q 430).

6.27.Many commercial organisations also provide training for environmental health officers and trading standards officers, including the Chartered Institute of Environmental Health (CIEH). The FSA noted that there was a "joint initiative between the Food Standards Agency Wales and CIEH Wales to raise awareness both of food allergy and intolerance issues with Welsh enforcement officers" (p 170). Mrs Hattersley added that once the courses are established, "what we want to do … is to then talk to the general training providers, including perhaps the undergraduate syllabuses for environmental health officers so that we can start to introduce allergy at a very early stage of training. That is certainly something we want to look at in the coming year" (Q 432). The Anaphylaxis Campaign also felt this was important, reporting that "we believe that the long-term solution to addressing the problem of food allergy in the catering sector lies in compulsory training programmes in allergy for food enforcement officers" (p 173).

KEY RECOMMENDATION

6.28.It is imperative that environmental health officers, trading standards officers and catering workers are adequately and comprehensively trained in practical allergen management. We welcome the development of a training programme by the Food Standards Agency and recommend that the FSA should work with other training providers to produce consistent practical training courses of a high standard.

Educating food allergic consumers

6.29.Whatever measures are taken to minimise the risks of allergen contamination, ultimately some responsibility must lie with the allergic consumer. However, the social difficulties caused by having a food allergy can sometimes make sufferers reluctant to take the necessary precautions. This is especially apparent amongst teenagers. A recent report commissioned by the FSA concluded that food allergies in teenagers often made social interactions difficult and so "it is therefore not surprising that there was evidence that young people were more likely to assume or guess that a particular dish was OK, or take a chance, than were their parents."[99] Other risk-taking behaviours reported by the FSA included "eating foods that carry 'May Contain' labelling, a reluctance to ask questions about the allergen content of foods, especially in restaurants, and not carrying their medication" (p 152).

6.30.The Anaphylaxis Campaign backed this up, and noted that almost all of the young people which attended their workshops "disregard 'may contain' warnings because they believe food companies are simply 'covering their backs' and that the hazard is not genuine" (p 172). The IFR also noted that teenagers "may not carry their adrenaline" and that young men "are at greater risk of not managing their food allergies adequately resulting in severe or even fatal reactions." The IFR commented that "there is a real danger that consumers are being deluged with information but that this is not provided in a targeted and useful way" to the at-risk groups (p 288).

6.31.The FSA has made considerable efforts to raise awareness of allergies amongst the general population. It reported that it had a "consumer-facing website[100] that contains a section on food allergy and intolerance issues" which included information on food allergies, advice about buying products, and an "Ask an Expert" function. It had also produced a factsheet for food allergy sufferers which helped them "successfully avoid the foods to which they know they react," and included information on understanding food labels and advice for when eating away from home" (p 153). Furthermore, Miss Fine said that the FSA was exploring new options to make consumers aware of mislabelling, including "an SMS texting initiative" for which allergic consumers could subscribe, to receive "immediate information" about labelling problems (Q 430).

6.32.The need to provide information regarding food allergies has been recognised internationally. The EU provided funding within its 5th and 6th Framework programmes to establish two research and information programmes, co-ordinated by the IFR. The EuroPrevall project aims to monitor the prevalence, basis and burden of food allergy across Europe, in addition to improving diagnostic methods, in order to improve patients' quality of life.[101] The Informall project has been established to "promote the provision of visible, credible food allergy information sources to a wide variety of stakeholders, including general consumers, the agro-food industry … allergic consumers, health professionals and regulators."[102] It has also developed a searchable database[103] of allergenic foods which contains information such as the clinical symptoms of each allergy, the types of foods that allergens may be found in, and possible cross-reactions.

6.33.We commend the way in which the Food Standards Agency has collaborated with relevant stakeholders to address allergen contamination problems in both prepacked food, and food sold in catering establishments. The Agency has made good progress in educating manufacturers, caterers, enforcement officers and allergic consumers about the dangers of allergen contamination in foods.

6.34.Many teenagers and young adults with food allergies sometimes take dangerously high risks when buying food. We therefore recommend that the Department of Health, working with the Food Standards Agency, charities and others, should explore novel ways to educate young people about allergy and the prevention of anaphylaxis.

Managing the indoor environment

6.35.In Chapter 5 we discussed the role that the indoor environment may play in the development or exacerbation of allergic diseases, but Dr Harrison told us that "there is a limit to what can be achieved through the building regulations" (Q 482) as "the behaviour of the occupants has a large impact on the conditions inside a house" (Q 485). Mr Ager echoed this by saying that "you can have the cleanest house and controlled environment but when you walk in you pollute it immediately" (Q 485).

6.36.It is therefore important that the general public are given adequate advice about how to manage their indoor environment appropriately. For example, Dr Harrison added that housedust mites "like living in pillows and mattresses so there are very practical things that can be done to reduce exposure by eliminating or at least removing either the source or exposure to the source of allergens in those materials" (Q 468). Mr Ager added that very simple precautions such as "steam cleaning furniture, changing bedding, boiling bedding and the introduction of floors like linoleum and laminate flooring" might reduce the incidence of asthma attacks (Q 465).

6.37.It appears that the general public are not aware of the health hazards associated with mismanagement of the indoor environment, especially poor ventilation. Mr John Bryson, Chair of the Commission on Housing Renewal and Public Health, CIEH, told us that "in older housing quite often what you find is that there is double-glazing put in which seals out all the drafts," so the dampness, the lack of ventilation and the increase in heat all provide the right growth conditions for housedust mites (Q 468). Dr Harrison agreed with this, noting that "even in more modern housing where ventilation is appropriately supplied people do not tend to like draughts and they will often stop up any ventilation bricks that they have in the home because they do not know that there is any dis-benefit of doing so" (Q 475).

6.38.In an attempt to improve information regarding the indoor environment, the DH has provided funding to the WHO to develop guidelines on indoor air quality (p 322). Furthermore, COMEAP, an advisory body which provides advice to Government bodies on matters concerning the health effects of air pollutants, has produced guidance on how to minimise indoor air pollutants which has been placed on the DH website.[104] Dr Harrison told us that these guidelines "line up very much with the WHO standards,"[105] but that "I do not think enough people have seen it" (Q 486).

6.39.In 1991 the House of Commons Environment Committee recommended that "the Government clarify and simplify existing responsibilities for indoor air quality and review the operations of the Interdepartmental Liaison Group on indoor air quality."[106] This Interdepartmental Liaison Group on indoor air quality had been established to consider a programme of commissioned work relating to indoor air, but Mr Lewis reported that its work ceased at "the end of the 1990s." Since then, responsibility for indoor air quality has fallen to different departments. The DCLG is now responsible for Building Regulations, whilst the DH is responsible for "the health aspects of indoor air" and works with the Health Protection Agency (HPA) to "provide advice on the impact on health of indoor air pollution" (pp 321-322, Q 849).

6.40.At a WHO conference in 2004, the Children's Environment and Health Action Plan for Europe was developed which aimed to address four key objectives relating to children's health and the environment. One of these four key objectives was to "ensure clean outdoor and indoor air." Ministers from the DH and Defra made a commitment to develop and implement a "Children's Environment and Health Strategy for the UK," and to co-ordinate this work the DH is chairing an Interdepartmental Steering Group. This steering group contains representatives from "other Government departments, Devolved Administrations, the Environment Agency, the Scottish Environment Protection Agency, the HPA, the Food Standards Agency and others" (p 322).

6.41.We recommend that the education of children about indoor air quality and its role in allergy development, should be a priority for the Interdepartmental Steering Group producing the "Children's Environment and Health Strategy."

The role of Government and charities

6.42.Throughout Chapters 5 and 6 we have discussed a wide range of issues which can affect the development of allergic disease, explored the ways in which allergic disorders can be prevented or managed, and highlighted the problems which allergic patients can face in everyday life. What unites all of these topics is the fact that management of the various factors requires a combination of both regulation and education. It is also clear that a very wide range of bodies—Government departments, non-departmental public bodies, local authorities and charities—all have a role in disseminating information and advice. In the final part of this chapter we briefly outline the ways in which information about allergy is disseminated, and the advice that is available to the general public.

THE ROLE OF GOVERNMENT

6.43.The Council for Science and Technology report, Health impacts—a strategy across Government, advised that although the Government had made large investments to modernise the National Health Service, there was a risk that "the positive effects stemming from this investment could be blunted, and the demands on the health service further intensified, if other Government departments do not sufficiently take into account the health impacts—either negative or positive—of their policies." It recommended that "a joint approach across Government involving Department of Health is needed."[107] Allergy exemplifies this.

6.44.Mr Lewis explained that to "make a reality of the rhetoric around joined-up government … at ministerial level, there is a Domestic Affairs Cabinet sub-committee on public health" underpinned by "a supportive structure at official level of programme boards, including the Health Improvement Board." The department had also made a number of efforts to work with other departments on specific policies, such as the publication of the Managing Medicines in Schools and Early Years Settings guidance produced jointly with the DfES, and the development of Building Regulations with the DCLG. With regards to children, the "Every Child Matters strategy" also sought to bring all government departments together to "look holistically at the needs of children and families" (Q 825).

6.45.In light of the alarming increase in the prevalence of allergic diseases, it is tempting to search for interventional strategies that the Government could recommend to help halt the trend. However, when asked whether there was any advice that should be issued routinely to prevent children developing allergies, Professor Sheikh warned us that "I think we need to appreciate that we are at a very early stage in this story" (Q 147). Professor Warner added that "I would love to be able to say that there were measures right now that one could recommend but there is none other than saying, 'Do not smoke in pregnancy' … 'Sustain a good diet,' and, 'Breast feed if at all possible.' I think beyond that at the moment we do not have enough evidence to make any other statements" (Q 97). Furthermore, Professor Custovic felt that "the day and age of simple public health advice where something is good for everybody is over. We are different individuals. What is very good for me may not necessarily work for you or may indeed really be bad for somebody else" (Q 498).

6.46.One area in which the DH has ventured to produce public advice is the dietary guidance issued for pregnant women and infants, and we now examine the consequences of this.

The development of food allergies

6.47.A key source of advice for pregnant women is the midwives who care for them. We invited the Royal College of Midwives to give evidence about early interventional strategies, but were disappointed that they were unable to field a representative to talk to us. Their written response noted that "breast feeding contains specific immunological properties" which may "to a certain extent protect children from certain diseases, especially asthma" so they therefore recommended "exclusive breastfeeding for the first six months without the introduction of supplements or solid foods" (p 384). Dr Hyer also noted that "in terms of primary prevention the best tool is to breast feed" (Q 659).

6.48.However, Professor Hourihane told us that "any allergen that a mother ingests—whether it is a food allergen or anything else—will be found in breast milk shortly afterwards" (Q 667). Therefore, Dr Hyer told us that "we know that if you have severe eczema you may benefit by going on to a hypoallergenic feed when weaned and not being fed cow's milk formula, but because of the diagnostic difficulties … selecting which patient should take on which avoidance pattern is very complicated" (Q 659).

6.49.Dr Rosenthal commented that "the Cochrane database on this aspect of prevention or food avoidance in pregnancy or lactation has been revised more often than any other Cochrane database, and the conclusion remains entirely the same; that there is no evidence—definitely no evidence—in terms of food avoidance during pregnancy, and during lactation possibly" (Q 661). There is therefore very limited advice which the Government can recommend.

6.50.Of all food allergens, the most dramatic increase in prevalence has been seen for peanut allergy. In 2002, the Isle of Wight Birth Cohort Study reported that peanut sensitisation had "increased three-fold" in children born between 1994 and 1996, compared to those born in 1989."[108] The risk factors for the development of peanut allergy are still uncertain. Previous research had suggested that exposure to peanut at an early, or even prenatal stage, could increase the risk of sensitisation. Therefore in The Pregnancy Book, issued freely to first time mothers, the DH recommends that pregnant women should avoid peanuts and foods containing peanut products "if you or your baby's father or any previous children have a history of hayfever, asthma, eczema or other allergies."[109] The DH publication, Birth to Five, also recommends that "breastfeeding mothers who are 'atopic', or those for whom the father or any sibling of the baby has an allergy, may wish to avoid eating peanuts or peanut products while breastfeeding," and goes further to say that peanuts or peanut products "should not be given to babies from 'atopic' or 'allergic' families until they are at least three years old."[110]

6.51.However, during a visit to the Evelina Children's Hospital, Professor Gideon Lack, Head of Paediatric Allergy, told us that a number of recent epidemiological studies had suggested that early peanut consumption, in countries such as Israel, was associated with a low incidence of peanut allergy in the population. This had led many academics to believe that repeated exposure of a child's immune system to peanut allergen at an early age might result in tolerance. If this was in fact the case, then Professor Lack noted that DH advice which recommended the avoidance of peanut, might actually be contributing to the increase in peanut allergy prevalence.[111] Currently, there is still no conclusive evidence to prove or disprove this theory, and as Dr Hyer told us, "we do not really know the answer" (Q 659).

6.52.To investigate these findings further, the Immune Tolerance Network has granted Professor Lack funding to carry out the Learning Early About Peanut allergy (LEAP) study. This interventional study aims to enrol 480 infants who suffer from egg allergy, eczema, or both, aged between four and 11 months old. Half of the infants will be prescribed a diet which contains peanut regularly, whilst the other half will be told to avoid peanut products. All of the participants will be asked to provide occasional blood samples, and will receive allergy testing, dietary counselling and physical examinations until the age of five. It is hoped that analysis of the proportion of children in each group which develops peanut allergy, will help to determine whether avoidance or consumption reduces the risk of developing the allergy.[112]

6.53.The DH told us that its advice was based upon the conclusions of the Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment (COT), which themselves were based on the "best available evidence when it reported in 1998." The Department recognised that "the then available evidence on development of peanut allergy during pregnancy and weaning was not conclusive but, noting the uncertainty and the potential for risk of life-threatening anaphylaxis, our advice on peanut allergy is precautionary" (p 26). Professor Warner, who was involved in the decision to recommend peanut avoidance, added that "although it was made in good faith at the time, based on evidence available, it was indirect evidence rather than direct evidence. Perhaps we have to be very cautious about any recommendations we make until we have got good evidence from controlled intervention rather than just observational studies" (Q 147).

6.54.The effect of Government advice on the prevalence of peanut allergy has recently been analysed by two research studies supported by the FSA. The results of one of these studies, published in April 2007, showed that Government advice concerning peanut consumption was often "misunderstood by mothers" and that those who communicated the advice had "not fully explained who it is targeted at." The report concluded that "the target population did not necessarily take up this advice" and that furthermore, some women who did not have a family history of atopy, at which the advice was not aimed, were avoiding peanuts. However, in summary it appeared that "maternal consumption of peanut during pregnancy was not associated with peanut sensitisation in the infant."[113]

6.55.In the second paper on peanut avoidance, it was noted that "no other government has issued such advice" and that "it has been a concern that the advice could possibly have adversely affected (increased) the prevalence of peanut allergy in the UK rather than decreasing the prevalence, as was the intention." However the paper also concluded that "we have not yet ascertained any positive or negative effect on the prevalence of peanut sensitisation or peanut allergy of the COT advice."[114]

6.56.When questioned about the adequacy of DH advice, Mr Lewis said that "if the advice is wrong or damaging or counterproductive, we ought to change it as quickly as possible" (Q 860). Following this, we were informed that the FSA "has already begun the process of identifying and systematically reviewing the evidence, and a paper will be taken to the COT as soon as this review is complete. The COT will then consider this evidence at an open committee meeting and will issue a statement. After that, the Government will reconsider its advice in the light of the views of the COT. Given the need to evaluate fully and carefully all the relevant scientific evidence, this process is likely to take six to 12 months" (p 322).

KEY RECOMMENDATION:

6.57.It is imperative that work is carried out to investigate whether peanut consumption or avoidance in early life significantly affects a child's risk of developing peanut allergy. We therefore support the work of the Learning Early About Peanut allergy (LEAP) study. We are very concerned that Department of Health dietary advice regarding peanut consumption for pregnant women and infants is based upon evidence that was reported nine years ago. Recent evidence suggests that this advice has not succeeded in reducing the prevalence of peanut allergy and may indeed be counterproductive. We recommend that this advice should be withdrawn immediately, pending a comprehensive review by the Food Standards Agency and the Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment.

THE ROLE OF CHARITIES

6.58.A number of charities provide support for patients with allergic disorders. Allergy UK is the operational name of the British Allergy Foundation, a charity which provides "information, advice and support to people with all types of allergy/intolerances and their carers" (p 291). Other charities, such as the Anaphylaxis Campaign, may focus on a particular subgroup of allergy sufferers or, in the case of Asthma UK and the National Eczema Society, may deal with conditions that can have both allergic and non-allergic causes.

6.59.Through the production of leaflets and guidance, or the use of workshops, helplines, support groups and websites, charities can provide an extra level of support for patients in addition to that received from their medical practitioner. There is a clear need for these services, as Allergy UK reported that 19,554 people used their telephone helpline service from March 2005 to April 2006 (p 291), and Asthma UK told us that it received "between 7,000 and 10,000 queries a year" (Q 779). Ms Lindsey McManus, Deputy Information Manager at Allergy UK, explained that patients phoned their helpline for a range of reasons. This might include queries about symptoms they were suffering or the basic question "could I have an allergy?" as well as questions about treatment such as "where is my nearest allergy clinic?" and "what type of test might I expect when I go to the hospital?" (Q 778).

6.60.Charities also provide practical information about how to manage allergic conditions. For example, Ms McManus told us that Allergy UK can offer "very practical advice such as bedding and cleaning. We can also give advice on different types of tests and alternative testing, should they ask us" (Q 778). Ms Donna Covey, who spoke to us as Chief Executive of Asthma UK, explained that the burden of allergic disease is not only caused by the symptoms, but also by the way in which it "impacts on your daily life." Asthma UK therefore ran "Kick Asthma holidays" which educated children about how to cope with asthma and other allergies. Children attending these courses often suffered from other allergies in addition to asthma, so at the start of the holidays children were encouraged to share information about all their allergies to get them out into the open. Ms Covey explained that this "normalises it and an understanding of allergy is a really important part of that work" (Q 780).

6.61.Following concerns that healthcare workers are not adequately educated about allergies, in some cases charities may also help to train medical professionals. The Anaphylaxis Campaign has developed a training programme for school nurses (p 174) and Allergy UK reported that it "provides education and training to healthcare professionals via masterclasses and an increasingly popular on-line e-learning European Diploma in Allergy accredited by the University of Greenwich" (p 292).

6.62.Furthermore, charities play an important role carrying out research for, and working with, Government departments and industry. As an example, following research undertaken by the Anaphylaxis Campaign, which demonstrated the difficulties that food allergic consumers faced when buying prepacked foods, the Anaphylaxis Campaign worked in collaboration with the FSA, the BRC, the Food and Drink Federation and LACORS to produce labelling guidance for food businesses.[115] With regard to occupational allergies, Asthma UK has worked in collaboration with the HSE, manufacturers and other organisations to produce a workplace charter to reduce the impact of asthma in the workplace.[116]

6.63.Considering the important role that allergy charities play, it was disappointing to hear that they had faced difficulties in receiving Government funding for their work. Ms Covey told us that Asthma UK provides "a number of what are really NHS plus services" but that its applications for funding often get turned down on the grounds that they overlap with NHS services. For example, previous applications for its helpline had been turned down "on the grounds that it overlaps with NHS Direct," but Ms Covey argued that it provided an additional service and that "NHS Direct nurses quite rightly often refer people with asthma to our nurses who can have a detailed chat about their asthma." Similarly, applications to fund health promotion materials had been refused "on the grounds that asthma self-management promotion is the job of the NHS and yet we know large parts of the health service do that really badly and when they do it well it is because they are using our materials" (Q 783).

6.64.Allergy charities play an important role in providing public advice, but must continue to work together and with clinical services to avoid duplication of work, and ensure that consistent, evidence-based policies and public advice are provided.

92 Statutory Instrument 2004 No. 2824. Similar legislation was also passed to implement this directive in Wales (S.I. 2004 No. 3022 (W.261), Scotland (S.I. 2004 No. 472) and Northern Ireland (S.I. 2004 No. 469). Back

93 Food Standards Agency, Guidance on Allergen Management and Consumer Information, 2006, pp 28-29. Back

94 McFadden et al, British Medical Journal 334, 2007, "Allergy to hair dye," p 220. Back

95 Statutory Instrument 2004 No. 2152. Back

96 European Commission Scientific Committee on Consumer Products, Memorandum on hair dye substances and their skin sensitising properties, 2006, p 5. Back

97 See: http://europa.eu/rapid/pressReleasesAction.do?reference=IP/07/439&type=HTML&aged=0&language=EN&guiLanguage=en. Back

98 Leitch et al, International Journal of Environmental Health Research 15, 2005, "Food allergy: Gambling your life on a take-away meal," pp 79-87. Back

99 op cit. Food Standards Agency, Qualitative Research into the Information Needs of Teenagers with Food Allergy and Intolerance, 2005, p. 38. Back

100 See www.eatwell.gov.uk. Back

101 See http://www.europrevall.org/. Back

102 See http://www.informall.eu.com/default.htm. Back

103 See http://foodallergens.ifr.ac.uk/. Back