582 LETTERS TO THE EDITOR

J ALLERGY CLIN IMMUNOL

FEBRUARY 2014

Henrike Tillandera
Niklas Andersson, MSca,e
Anna Bergstr
om, PhDa
Inger Kull, PhDb,f,g
Erik Mel
en, MD, PhDa,b,g
G
oran Pershagen, MD, PhDa,e
Staffan Ahlstedt, PhDa,g
Gunnar Lilja, MD, PhDb,f
Marianne van Hage, MD, PhDd
on behalf of the MeDALL consortium
From athe National Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden; bthe Department of Pediatrics, Sachs Childrens Hospital, Stockholm,
Sweden; cAstrid Lindgren Childrens Hospital, Stockholm, Sweden; dthe Clinical
Immunology and Allergy Unit, Department of Medicine Solna, Karolinska Institutet
and University Hospital, Stockholm, Sweden; ethe Centre for Occupational and Environmental Medicine, Stockholm County Council, Stockholm, Sweden; fthe Department of Clinical Science and Education, Karolinska Institutet at Sodersjukhuset,
Stockholm, Sweden; and gthe Centre for Allergy Research, Karolinska Institutet,
Stockholm, Sweden. E-mail: magnus.wickman@ki.se.
*These authors contributed equally to this work.
This study was supported by the Swedish Asthma and Allergy Associations Research
Foundation, the Foundation for Health Care Sciences and Allergy Research, the
Centre for Allergy Research (CfA), the Stockholm County Council, and the Swedish
Research Council, Sweden. Thermo Fisher Scientific kindly provided the reagents for
the study. None of the funding sources had a role in the study design, conduct, analysis, or reporting.
Disclosure of potential conflict of interest: M. Wickman has received a grant and a
consulting fee from Thermo Fisher and has received payment for lectures from
ALK-Abell
o and GlaxoSmithKline. A. Asarnoj has received a grant from Thermo
Fisher. M. van Hage has received payment for lectures from Thermo Fisher Scientific,
Novartis, and ALK-Abell
o. The rest of the authors declare that they have no relevant
conflicts of interest.
REFERENCES
1. Kulig M, Bergmann R, Klettke U, Wahn V, Tacke U, Wahn U. Natural course of
sensitization to food and inhalant allergens during the first 6 years of life. J Allergy
Clin Immunol 1999;103:1173-9.
2. Eller E, Kjaer HF, Host A, Andersen KE, Bindslev-Jensen C. Food allergy and
food sensitization in early childhood: results from the DARC cohort. Allergy
2009;64:1023-9.
3. Borres MP, Ebisawa M, Eigenmann PA. Use of allergen components begins a new
era in pediatric allergology. Pediatr Allergy Immunol 2011;22:454-61.
4. Asarnoj A, Moverare R, Ostblom E, Poorafshar M, Lilja G, Hedlin G, et al. IgE to
peanut allergen components: relation to peanut symptoms and pollen sensitization
in 8-year-olds. Allergy 2010;65:1189-95.
5. Kull I, Almqvist C, Lilja G, Pershagen G, Wickman M. Breast-feeding reduces the
risk of asthma during the first 4 years of life. J Allergy Clin Immunol 2004;114:
755-60.
6. Ballardini N, Kull I, Lind T, Hallner E, Almqvist C, Ostblom E, et al. Development
and comorbidity of eczema, asthma and rhinitis to age 12: data from the BAMSE
birth cohort. Allergy 2012;67:537-44.
7. Mittag D, Vieths S, Vogel L, Becker WM, Rihs HP, Helbling A, et al. Soybean
allergy in patients allergic to birch pollen: clinical investigation and molecular
characterization of allergens. J Allergy Clin Immunol 2004;113:148-54.
Available online October 23, 2013.
http://dx.doi.org/10.1016/j.jaci.2013.09.009

Access to health care and food in children with

food allergy
To the Editor:
Reduced access to health care and food in the United States
is associated with poor health outcomes,1-3 and facilitating
access to providers, medications, and food has led to measured
improvements in public health.4,5 Food allergy is a common
chronic condition affecting 4% to 8% of US children that is
increasing in prevalence for unclear reasons.6,7 Whether patients
with food allergy experience impaired access to health care
and food is currently unknown. Minority populations share a

significant burden of food allergy,7,8 and the rate of increase in

food allergy in black children might be twice that in white
children.7 We were interested in whether subjects with food
allergy report reduced access to health care and food and how
this is associated with race/ethnicity because this could influence
disease outcome.
We examined data from the 2011 and 2012 National Health
Interview Survey (NHIS), a household interview survey of the US
population covering a range of health topics. In each household an
adult answered questions about a randomly chosen child in the
household. We considered a child to have food allergy if the
responding adult answered yes to the following question: During
the past 12 months, has the sample child had any kind of food or
digestive allergy? We used the adults responses to questions
regarding the childs access to health care and the familys access
to food as measures of access to health care and food. Access to
food was defined by using the US Department of Agriculture
(USDA)s definition of food security, a measure of consistency
of access to enough food for an active healthy life. Please
see the supplementary text in this articles Online Repository at
www.jacionline.org for additional information regarding the
access measures, NHIS methodology, and variable definitions.
Statistical analyses were performed with STATA 12.0 software
(StataCorp, College Station, Tex). We used the x2 test to
determine whether subjects with and without food allergy differed
by demographic and access factors. We used logistic regression to
determine the association between race/ethnicity and access and
adjusted for sex, age, family income, and education in a nested
fashion. We incorporated survey weighting, sampling units, and
strata in the primary x2 analysis, but because subjects were not
equally distributed among the strata, only survey weights were
incorporated in the x2 analysis stratified by race and in the logistic
regression models.
Complete data were available for 26,021 children from the
combined 2011-2012 data set, of whom 1,351 (5.59%) reported
food allergy. Of the children with food allergy, 54.8% were
white, 17.1% were black/African American, 17.7% were
Hispanic/Latino/Spanish, and 10.4% were classified as other
(see Table E1 in this articles Online Repository at www.
jacionline.org). Food allergy in the sample child was more
common in families with a higher level of education and a
higher household income, which is in line with previously
reported demographic trends.6,9 The survey population was
equally distributed between sexes and among age groups.
Among children with food allergy, 20.95% were determined to
have low food security, 33.53% reported having problems paying
family medical bills, 4.47% reported not being able to afford
needed prescriptions, 4.14% reported not being able to
afford needed specialist care, 2.76% reported not being able to
afford needed follow-up care, 2.45% reported having trouble
finding a doctor to see the child, and 4.11% reported having no
family member with health insurance (Fig 1, A, and see Table E1).
With the exception of having family members without insurance,
these values are all significantly higher than those for children
_ .05), and similar trends were observed
without food allergy (P <
when stratifying by race/ethnicity (see Table E2 in this articles
Online Repository at www.jacionline.org).
Compared with white children with food allergy, after
adjusting for age and sex, black children with food allergy were
significantly more likely to have low food security (odds ratio
[OR], 3.31; 95% CI, 2.17-5.06), to have problems paying family

J ALLERGY CLIN IMMUNOL

VOLUME 133, NUMBER 2

LETTERS TO THE EDITOR 583

FIG 1. A, Percentage of subjects with food allergy reporting impaired food security or reduced access to
health care. B, Distribution of subjects with food allergy reporting impaired food security or reduced access
to health care by race/ethnicity.

medical bills (OR, 2.28; 95% CI, 1.55-3.35), and to be unable

to afford needed prescriptions (OR, 3.44; 95% CI, 1.68-7.02;
Fig 1, B, and Table I). Hispanic children with food allergy
were more likely to have low food security (OR, 2.44; 95%
CI, 1.61-3.70), to have problems paying family medical bills
(OR, 1.56; 95% CI, 1.08-2.23), and to be unable to afford needed
prescriptions (OR, 2.38; 95%, CI 1.13-5.03) and follow-up care
(OR, 3.74; 95% CI, 1.70-8.24). Many of these associations
were attenuated after further adjusting for income and parental
education. However, even after incorporating these variables,
black respondents with food allergy were significantly more
likely to have low food security (OR, 2.15; 95% CI, 1.30-3.53),
to have problems paying family medical bills (OR, 1.68; 95%
CI, 1.09-2.59), and to have trouble affording prescriptions for
the child (OR, 2.40; 95% CI, 1.14-5.05) and Hispanic respondents
with food allergy were significantly more likely to have trouble
affording follow-up care (OR, 3.02; 95% CI, 1.34-6.81; Table I)
compared with white respondents with food allergy. There were
no significant race/ethnicity differences in the ability to afford
specialist care or difficulty finding a doctor to see the child. Black
respondents with food allergy were more likely in all models to
have any family member with health insurance. We next
compared children with food allergy with those with other

chronic medical conditions and found that children with food

allergy have similar or greater difficulty with access to care and
food as children with other chronic medical conditions, with
similar racial/ethnic disparities as in the previous analysis
(see Table E3 in this articles Online Repository at www.
jacionline.org).
In this large national survey we examined access to health care
and food among subjects with food allergy, a chronic disease
increasing in prevalence. We found that compared with subjects
without food allergy, subjects with food allergy are significantly
more likely to report difficulty with access to care and food.
Furthermore, parents of nonwhite children with food allergy were
significantly more likely to report difficulty affording medical
care and medications and low food security compared with
parents of white children with food allergy. Not surprisingly,
many of these associations were attenuated when we included
parental income and education in the analysis. However, we were
surprised that even after adjusting for income and education,
black respondents with food allergy were significantly
more likely to report low food security and trouble affording
prescriptions and Hispanic respondents with food allergy were
significantly more likely to report trouble affording follow-up
care compared with white respondents. Although it might be

584 LETTERS TO THE EDITOR

J ALLERGY CLIN IMMUNOL

FEBRUARY 2014

TABLE I. Racial/ethnic disparities in likelihood of poor food security and reduced health care access among children with food allergy

Crude OR (95% CI)

Low or very low food security

White
Black/African American
Hispanic/Latino/Spanish
Other
Problems paying family medical bills
White
Black/African American
Hispanic/Latino/Spanish
Other
Cannot afford prescriptions for child
White
Black/African American
Hispanic/Latino/Spanish
Other
Cannot afford specialist care for child
White
Black/African American
Hispanic/Latino/Spanish
Other
Cannot afford follow-up care for child
White
Black/African American
Hispanic/Latino/Spanish
Other
Trouble finding a doctor to see child
White
Black/African American
Hispanic/Latino/Spanish
Other
No insurance in family
White
Black/African American
Hispanic/Latino/Spanish
Other

Model 1: Adjusted
for childs age
and sex

Model 2: Model 1
adjusted for
parental education

Model 3: Model 1
adjusted for
income group

Full model

1.00
3.39
2.45
1.16

(reference)
(2.21-5.19)
(1.61-3.71)
(0.62-2.14)

1.00
3.31
2.44
1.17

(reference)
(2.17-5.06)
(1.61-3.70)
(0.63-2.18)

1.00
2.63
1.63
1.18

(reference)
(1.64-4.22)
(1.04-2.57)
(0.63-2.23)

1.00
2.20
1.67
1.20

(reference)
(1.36-3.56)
(1.07-2.62)
(0.64-1.73)

1.00
2.15
1.47
1.19

(reference)
(1.30-3.53)
(0.92-2.34)
(0.62-2.27)

1.00
2.30
1.57
0.76

(reference)
(1.57-3.38)
(1.09-2.25)
(0.48-1.20)

1.00
2.28
1.56
0.76

(reference)
(1.55-3.35)
(1.08-2.23)
(0.48-1.21)

1.00
1.95
1.21
0.75

(reference)
(1.29-2.93)
(0.82-1.80)
(0.47-1.21)

1.00
1.69
1.23
0.81

(reference)
(1.10-2.60)
(0.83-1.83)
(0.49-1.35)

1.00
1.68
1.18
0.81

(reference)
(1.09-2.59)
(0.78-1.79)
(0.49-1.35)

1.00
3.34
2.29
0.23

(reference)
(1.65-6.74)
(1.07-4.89)
(0.05-1.15)

1.00
3.44
2.38
0.23

(reference)
(1.68-7.02)
(1.13-5.03)
(0.05-1.16)

1.00
3.13
2.02
0.24

(reference)
(1.50-6.50)
(0.88-4.61)
(0.05-1.16)

1.00
2.37
1.76
0.23

(reference)
(1.13-4.98)
(0.80-3.92)
(0.05-1.17)

1.00
2.40
1.78
0.23

(reference)
(1.14-5.05)
(0.77-4.10)
(0.05-1.18)

1.00
0.44
1.22
0.44

(reference)
(0.15-1.26)
(0.51-2.91)
(0.13-1.52)

1.00
0.43
1.25
0.45

(reference)
(0.15-1.25)
(0.52-3.00)
(0.13-1.56)

1.00
0.39
1.08
0.45

(reference)
(0.14-1.11)
(0.46-2.57)
(0.13-1.56)

1.00
0.35
1.08
0.45

(reference)
(0.12-0.96)
(0.48-2.42)
(0.13-1.60)

1.00
0.34
1.06
0.45

(reference)
(0.13-0.95)
(0.47-2.42)
(0.13-1.60)

1.00
0.85
3.65
0.63

(reference)
(0.30-2.40)
(1.67-8.01)
(0.11-3.68)

1.00
0.85
3.74
0.64

(reference)
(0.30-2.40)
(1.70-8.24)
(0.11-3.71)

1.00
0.76
3.18
0.64

(reference)
(0.26-2.17)
(1.41-7.17)
(0.11-3.69)

1.00
0.59
2.92
0.65

(reference)
(0.20-1.71)
(1.30-6.56)
(0.11-3.83)

1.00
0.59
3.02
0.65

(reference)
(0.20-1.72)
(1.34-6.81)
(0.11-3.84)

1.00
1.00
1.30
2.06

(reference)
(0.27-3.70)
(0.46-3.64)
(0.68-6.24)

1.00
0.97
1.29
2.12

(reference)
(0.26-3.56)
(0.47-3.57)
(0.71-6.36)

1.00
0.80
1.00
2.12

(reference)
(0.20-3.28)
(0.35-2.89)
(0.70-6.36)

1.00
0.85
1.19
2.17

(reference)
(0.20-3.56)
(0.42-3.35)
(0.71-6.60)

1.00
0.82
1.02
2.16

(reference)
(0.19-3.51)
(0.35-2.97)
(0.72-6.54)

1.00
0.21
1.66
0.65

(reference)
(0.05-0.92)
(0.82-3.38)
(0.19-2.20)

1.00
0.23
1.74
0.63

(reference)
(0.05-1.00)
(0.85-3.57)
(0.19-3.57)

1.00
0.17
1.16
0.65

(reference)
(0.04-0.77)
(0.54-2.48)
(0.19-2.19)

1.00
0.15
1.24
0.62

(reference)
(0.03-0.65)
(0.56-2.73)
(0.18-2.13)

1.00
0.14
1.10
0.63

(reference)
(0.03-0.63)
(0.51-2.39)
(0.18-2.16)

Values in boldface are statistically significant.

unsurprising that families of children with food allergies report

more trouble accessing health care than families of children
without food allergy, we did find that families of children with
food allergy report at least as much, if not more, trouble accessing
health care as families of children with other chronic diseases
(see Table E3 and the supplemental text in this articles Online
Repository). Our results suggest there might be a barrier to
accessing health care and food in children with food allergy,
particularly among nonwhite children. Poor access to health
care and food might increase morbidity, especially among
minority children, by imposing poor nutrition and delayed
treatment for allergic reactions.
Associations drawn from cross-sectional studies are only a first
step in understanding the association between food allergy and
access to care. Our study is limited by the use of parental report of
food or digestive allergy within the last year. This might
overestimate or underestimate food allergy prevalence, and
further validation studies are needed to perform populationbased studies of food allergy. However, parent-reported food
allergy prevalence in our sample falls within the range of
previously reported estimates and has been used in many
epidemiologic studies of food allergy.6,7,9 Our cross-sectional

study is also limited by the possibility of reverse causation in

that decreased access to health care and food might increase
the likelihood of self-report of food allergy. However, we
incorporated potentially important socioeconomic confounders,
such as income and education, into our analyses, making this
effect less likely. We were also limited by our inability to
incorporate the full sampling design into our analysis because
of the distribution of subjects within strata. Therefore our
estimates are not necessarily nationally representative. However,
this study is notable because it is the first to examine access to
care among patients with food allergy and includes more than
1000 subjects with parent-reported food allergy, nearly 50% of
whom are nonwhite.
In summary, we have demonstrated that subjects with food
allergy report difficulty with access to medical care and food
and that there are significant disparities in access associated with
race/ethnicity. We were surprised that many of these disparities
persisted after adjusting for income and education, which
might be explained by sociocultural factors and needs further
investigation. Given the increasing burden of food allergy,
particularly among children of black/African American ethnicity,
our results might have significant public health implications.

LETTERS TO THE EDITOR 585

J ALLERGY CLIN IMMUNOL

VOLUME 133, NUMBER 2

Further study is necessary to determine whether impaired access

to care in patients with food allergy is associated with increased
morbidity and whether improvements in access can improve
disease outcome, as has been shown for patients with other
allergic diseases, such as asthma.4
Christina B. Johns, BAa
Jessica H. Savage, MD, MHSa,b
From athe Division of Rheumatology, Immunology, and Allergy, Brigham and Womens
Hospital, and bHarvard Medical School, Boston. E-mail: jrsavage@partners.org.
Supported in part by grants from the American Academy of Allergy, Asthma &
Immunology and FARE and a KL2 Medical Research Investigator Training award
(an appointed KL2 award) from Harvard Catalyst j The Harvard Clinical and
Translational Science Center (National Center for Research Resources and the
National Center for Advancing Translational Sciences, National Institutes of Health
Award 1KL2 TR001100-01 to J.H.S.).
Disclosure of potential conflict of interest: The authors have received research support
from the National Institutes of Health and the American Academy of Allergy,
Asthma & Immunology.

REFERENCES
1. Jones R, Lin S, Munsie JP, Radigan M, Hwang SA. Racial/ethnic differences in
asthma-related emergency department visits and hospitalizations among children
with wheeze in Buffalo, New York. J Asthma 2008;45:916-22.
2. Cook JT, Frank DA, Berkowitz C, Black MM, Casey PH, Cutts DB, et al. Food
insecurity is associated with adverse health outcomes among human infants and
toddlers. J Nutr 2004;134:1432-8.
3. Price JH, Khubchandani J, McKinney M, Braun R. Racial/ethnic disparities in
chronic diseases of youths and access to health care in the United States. Biomed
Res Int 2013;2013:787616.
4. Fox P, Porter PG, Lob SH, Boer JH, Rocha DA, Adelson JW. Improving
asthma-related health outcomes among low-income, multiethnic, school-aged
children: results of a demonstration project that combined continuous quality
improvement and community health worker strategies. Pediatrics 2007;120:
e902-11.
5. Kowaleski-Jones L, Duncan GJ. Effects of participation in the WIC program on
birthweight: evidence from the National Longitudinal Survey of Youth. Special
Supplemental Nutrition Program for Women, Infants, and Children. Am J Public
Health 2002;92:799-804.
6. Gupta RS, Springston EE, Warrier MR, Smith B, Kumar R, Pongracic J, et al. The
prevalence, severity, and distribution of childhood food allergy in the United
States. Pediatrics 2011;128:e9-17.
7. Keet CA, Savage JH, Seopaul S, Peng RD, Wood RA, Matsui EC. Temporal trends
and recent racial/ethnic disparities in pediatric food allergy in the US. Ann Allergy
Asthma Immunol 2014 [in press].
8. Taylor-Black S, Wang J. The prevalence and characteristics of food
allergy in urban minority children. Ann Allergy Asthma Immunol 2012;
109:431-7.
9. McGowan EC, Keet CA. Prevalence of self-reported food allergy in the National
Health and Nutrition Examination Survey (NHANES) 2007-2010. J Allergy Clin
Immunol 2013;132:1216-9.

http://dx.doi.org/10.1016/j.jaci.2013.12.006

Specific IgE reactivity to Tri a 36 in children

with wheat food allergy
To the Editor:
Wheat is an important part of our daily diet, but it can also elicit
IgE-associated allergic reactions after ingestion in 0.5% to 1% of
the population.1 In patients with wheat allergy, intake of
wheat-containing food can lead to immediate wheat food allergy,
which occurs in children, or to wheat-dependent exercise-induced
anaphylaxis, which has been reported to affect adults. The use of
natural wheat allergen extracts for serological testing for
wheat-induced food allergy may deliver specific IgE reactivities

FIG 1. Coomassie-stained SDS-PAGE containing purified recombinant Tri a

36 and Tri a 19. A molecular weight marker (M) was used as standard.

that are not associated with clinically relevant sensitization in

patients with grass pollen allergy.2
Therefore, Tri a 19, an omega-5-gliadin, which has been
described as a major allergen in immediate allergy in children3
and wheat-dependent exercise-induced anaphylaxis,4 is widely
used for serological testing for wheat-induced food allergy. Tri
a 19 has recently also been used to establish a murine model
for wheat allergy in mice,5 and its utility for the diagnosis of
wheat allergy was confirmed in a pediatric multicenter challenge
study.6
We have recently identified a low molecular weight glutenin as
new major wheat food allergen Tri a 36 and expressed and purified
the recombinant allergen rTri a 36.7 Here, we compared its IgEbinding frequency in an IgE ELISA performed as described,8
with the routinely used wheat allergen extract and Tri a 19 ImmunoCAPs (Thermo Fisher Scientific Inc, Uppsala, Sweden). Fig 1
shows a comparison of purified rTri a 36 and rTri a 19. Specific
IgE antibodies were measured in sera from selected groups of
patients, that is, children with wheat food allergy (n 5 37),
patients with grass pollen allergy (n 5 15), and patients with
atopic dermatitis (AD) (n 5 16) (see Table E1 in this articles
Online Repository at www.jacionline.org). Children with
wheat food allergy (w1-w37) had a clear clinical history (see
the Online Repository at www.jacionline.org) of wheat food
allergy with symptoms clearly attributable to wheat ingestion
(Table E1). Patients with grass pollen allergy (g1-g15)
suffered from grass polleninduced respiratory allergy but
regularly ate wheat products without any clinical symptoms.
Patients with AD (AD1-AD16) suffered from various sensitizations but also regularly ate wheat products without symptoms
(Table E1).
When we used wheat extractbased ImmunoCAP, all but 1 of
the patients with wheat food allergy showed wheat-specific IgE
but 12 (ie, 80%) of the 15 patients with grass pollen allergy and 13
(81%) of the 16 patients with AD without clinical symptoms to
wheat showed IgE reactivity to the wheat extract (Fig 2, A, left
panel; Table E1). The positive reactions to wheat in patients
with grass pollen allergy and patients with AD could possibly
be explained by IgE cross-reactivity with clinically irrelevant antigens in food allergy.2 Two cross-reactive allergens in pollen and
plant food without or with low clinical relevance in food allergy
are Phl p 4associated carbohydrates as well as profilins. In
fact, 46% and 43% of the patients with grass pollen allergy and
AD, respectively, showed IgE reactivity to natural Phl p 4 by
ISAC chip analysis (Thermo Fisher Scientific).9 The other

585.e1 LETTERS TO THE EDITOR

ACCESS TO HEALTH CARE

Access to health care is assessed with questions regarding a
subjects ability to afford needed medications, having a usual
source of care, and use of nonemergency physician visits. There is
no standardized questionnaire to assess health care access.
Reduced access to care has been associated with morbidity in
patients with chronic diseases, including childhood asthma.E1,E2
Asthma morbidity, which is often measured by an increase in
emergency department/urgent care visits and hospitalization
rates, is greater in inner-city minority children, who also
demonstrate reduced use of nonemergency follow-up care.E1,E3,E4
Programs targeted at improving access to health care through
community health centers and schools have been successful at
improving asthma outcomes.E5,E6 To our knowledge, access to
health care has not been previously evaluated in food allergy.
ACCESS TO FOOD
Access to food is measured by family food security, which is
defined by the USDA as access by all people at all times to
enough food for an active, healthy life and is determined based
on answers to a food security survey administered to families
consisting of questions about the conditions and behaviors of the
family as a whole, adults, and children related to their ability to
meet basic needs for food.E7 Food insecurity is independently
associated with delays in seeking care and obtaining medications,
as well as increased urgent care visitsE8 and in children has been
associated with poor general health and hospitalizations.E9 Food
assistance programs, such as the Special Supplementation
Nutrition Program for Women, Infants, and Children, have
demonstrated improved health outcomes.E10 Appropriate nutrition within the limits of restricted diets is especially important
for children with food allergiesE11; however, the incidence of
food insecurity and implications for morbidity in this population
have not been previously examined.
METHODS
Data were obtained from the NHIS, which is accessed through the Centers
for Disease Control and Prevention. The NHIS is conducted annually by the
National Center for Health Statistics. Households are selected as part of a
probability sample representative of the noninstitutionalized US population,
and a sample adult is chosen to answer questions regarding the health of the
family and of one child randomly chosen from those in each household.E12

Variable definitions
We used answers to the following questions as measures of food and health
care access:
d

d
d

In the past 12 months, did you or anyone in the family have problems
paying or were unable to pay any medical bills? Include bills for
doctors, dentists, hospitals, therapists, medication, equipment, nursing
home, or home care.
During the past 12 months, was there any time when the sample child needed
any of the following but did not get it because you could not afford it?
A. Prescription medicines
B. To see a specialist
C. Follow-up care
During the past 12 months, did you have any trouble finding a general
doctor or provider who would see the sample child?
Are you/is anyone in the family covered by any kind of health
insurance or some other kind of health care plan?

J ALLERGY CLIN IMMUNOL

FEBRUARY 2014

Family food security, which is defined as access by all people at all

times to enough food for an active, healthy life was determined
according to the USDAs guidelinesE7 and was dichotomized as
secure or not secure.

Race and ethnicity were defined by self-report and were categorized as nonHispanic white, non-Hispanic black/African American, Hispanic/Spanish/
Latino, and non-Hispanic other. Income and level of education of the most
educated adult in the household were grouped, as shown in Table E1. These
were incorporated into the model as dummy variables.

Analysis of access to health care and food among

children with other chronic medical problems
To contextualize our results, we compared access to health care and food
among children with food allergy with access among children with other
chronic medical conditions that also require medications, specialist care, and
follow-up care. We included children with cystic fibrosis, sickle cell anemia,
diabetes, arthritis, congenital heart disease, other heart conditions, asthma, or
anemia in this group. Respondents who answered yes to any of the following
questions and no to During the past 12 months, has the sample child had any
kind of food or digestive allergy? were included in the other chronic
medical conditions group.
d

d
d

Looking at this list, has a doctor or health professional ever told you
that the sample child had any of these conditions?
A. Cystic fibrosis
B. Sickle cell anemia
C. Diabetes
D. Arthritis
E. Congenital heart disease
F. Other heart condition
Has a doctor or other health professional ever told you that the sample
child had asthma? Also, does the sample child still have asthma?
During the past 12 months, has the sample child had anemia?

Respondents who answered yes to the question During the past 12 months,
has the sample child had any kind of food or digestive allergy? were included
in the food allergy group, including respondents who answered yes to having
food allergy and another chronic condition.
We used logistic regression to determine the odds of reporting poor access
to health care and food for children with food allergy compared with children
with the above medical conditions and adjusted for sex, age, family income,
and education. Because subjects were not equally distributed among the strata,
only survey weights were incorporated in the logistic regression model. The
results are shown in Table E3.
REFERENCES
E1. Akinbami LJ, Moorman JE, Garbe PL, Sondik EJ. Status of childhood asthma in
the United States, 1980-2007. Pediatrics 2009;123(Suppl 3):S131-45.
E2. Mansour ME, Lanphear BP, DeWitt TG. Barriers to asthma care in urban
children: parent perspectives. Pediatrics 2000;106:512-9.
E3. Price JH, Khubchandani J, McKinney M, Braun R. Racial/ethnic disparities in
chronic diseases of youths and access to health care in the United States. Biomed
Res Int 2013;2013:787616.
E4. Jones R, Lin S, Munsie JP, Radigan M, Hwang SA. Racial/ethnic differences in
asthma-related emergency department visits and hospitalizations among children
with wheeze in Buffalo, New York. J Asthma 2008;45:916-22.
E5. Fox P, Porter PG, Lob SH, Boer JH, Rocha DA, Adelson JW. Improving
asthma-related health outcomes among low-income, multiethnic, school-aged
children: results of a demonstration project that combined continuous quality
improvement and community health worker strategies. Pediatrics 2007;120:
e902-11.
E6. Levy M, Heffner B, Steeart T, Beeman G. The efficacy of asthma case management in an urban school district in reducing school absences and hospitalizations
for asthma. J Sch Health 2006;76:320-4.
E7. Coleman-Jensen A, Nord M, Singh A. Household food security in the United
States in 2012, ERR-155. Washington (DC): US Department of Agriculture,
Economic Research Service; 2013.

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VOLUME 133, NUMBER 2

E8. Kushel MB, Gupta R, Gee L, Haas JS. Housing instability and food insecurity as
barriers to health care among low-income Americans. J Gen Intern Med 2006;21:
71-7.
E9. Cook JT, Frank DT, Berkowitz C, Black MM, Casey PH, Cutts DB, et al. Food
insecurity is associated with adverse health outcomes among human infants and
toddlers. J Nutr 2004;134:1432-8.
E10. Kowaleski-Jones L, Duncan GJ. Effects of participation in the WIC program on
birthweight: evidence from the National Longitudinal Survey of Youth. Special

LETTERS TO THE EDITOR 585.e2

Supplemental Nutrition Program for Women, Infants, and Children. Am J Public

Health 2002;92:799-804.
E11. Mehta H, Groetch M, Wang J. Growth and nutritional concerns in children with
food allergy. Curr Opin Allergy Clin Immunol 2013;13:275-9.
E12. National Center for Health Statistics. National Health Interview Survey
questionnaires, datasets, and related documentation 1997 to the present. 20112012 June 27, 2013. Available at: http://www.cdc.gov/nchs/nhis/quest_data_related_
1997_forward.htm. Accessed August 2013.

585.e3 LETTERS TO THE EDITOR

J ALLERGY CLIN IMMUNOL

FEBRUARY 2014

TABLE E1. Sociodemographic characteristics and reported access

to health care and food among children with and without food
allergy
Food allergy

Overall
Sex
Male
Female
Age (y)
0-5
6-11
12-17
Ethnicity
White
Black/African American
Hispanic/Latino/Spanish
Other
Annual family income
<$35,000
$35,000-$74,999
>
_$75,000
Highest level of parental education
High school diploma or less
Some college or Associates degree
Bachelors degree or higher
Food security
Secure
Not secure
Problems paying family medical bills
Cannot afford prescriptions for child
Cannot afford specialist care for child
Cannot afford follow-up care for child
Trouble finding a doctor to see child
No insurance in family

Yes
(n 5 1,351)

No
(n 5 24,670)

5.59%

94.41%

51.56%
48.44%

51.10%
48.90%

32.02%
36.14%
31.83%

33.78%
33.13%
33.09%

54.83%
17.07%
17.72%
10.39%

53.51%
13.57%
24.26%
8.66%

35.76%
25.78%
38.46%

33.53%
30.75%
35.72%

23.08%
34.86%
42.06%

30.35%
33.68%
35.97%

79.05%
20.95%
33.53%
4.47%
4.14%
2.76%
2.45%
4.11%

83.91%
16.09%
22.64%
2.13%
1.30%
1.19%
1.58%
3.89%

P
value

.80

.20

<.001

.006

<.001

<.001
<.001
<.001
<.001
<.001
.05
.77

LETTERS TO THE EDITOR 585.e4

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VOLUME 133, NUMBER 2

TABLE E2. Reported access to health care and food stratified by race/ethnicity
White

Black/African American

Hispanic/Latino/Spanish

Other

Not allergic Allergic

P
Not allergic Allergic
P
Not allergic Allergic
P
Not allergic Allergic
P
to food
to food value
to food
to food value
to food
to food value
to food
to food value

Low or very low food security

Problems paying family medical bills
Cannot afford prescriptions for child
Cannot afford specialist care for child
Cannot afford follow-up care for child
Trouble finding a doctor to see child
No insurance in family
Values in boldface are statistically significant.

11.82%
21.41%
1.41%
0.96%
0.75%
1.36%
3.06%

14.5%
.10
28.41% <.001
3.01% .004
4.66% <.001
1.95% .002
2.11% .20
4.34% .19

23.03%
26.28%
2.55%
1.28%
1.28%
1.37%
2.24%

36.25% <.001
48.86% <.001
9.38% <.001
2.09% .30
1.71% .53
2.06% .48
0.95% .21

22.56%
24.56%
3.58%
2.14%
2.18%
2.06%
6.33%

28.42% .07
39.51% <.001
6.45% .05
5.68% .004
7.10% <.001
2.72% .49
7.11% .62

13.51%
19.16%
1.89%
1.05%
0.97%
1.96%
4.84%

17.16%
25.03%
0.76%
2.19%
1.34%
4.43%
3.00%

.34
.13
.23
.22
.72
.08
.38

585.e5 LETTERS TO THE EDITOR

J ALLERGY CLIN IMMUNOL

FEBRUARY 2014

TABLE E3. Likelihood of reduced access to health care and food among children with food allergy compared with children with other
chronic medical conditions both overall and stratified by race/ethnicity*
Overall

Problems paying family medical bills

Cannot afford prescriptions for child
Cannot afford specialist care for child
Cannot afford follow-up care for child
Trouble finding a doctor to see child
No insurance in family
Low or very low food security

1.36
1.04
1.94
1.69
1.12
2.32
1.15

(1.12-1.65)
(0.72-1.51)
(1.16-3.23)
(1.03-2.75)
(0.67-2.88)
(1.45-3.73)
(0.92-1.44)

White

1.10
0.81
2.05
1.46
1.78
2.67
1.04

(0.81-1.48)
(0.43-1.51)
(0.95-4.42)
(0.65-3.28)
(0.71-4.46)
(1.22-5.82)
(0.70-1.53)

Black/African American

2.44
2.28
0.83
0.97
0.78
0.56
1.52

(1.64-3.61)
(1.16-4.47)
(0.27-2.56)
(0.28-3.36)
(0.24-2.55)
(0.06-5.21)
(1.01-2.29)

Hispanic/Latino/Spanish

1.44
0.83
2.59
2.27
0.56
2.12
1.18

(1.01-2.06)
(0.41-1.68)
(1.00-6.70)
(1.10-4.69)
(0.22-1.43)
(1.10-4.09)
(0.79-1.77)

Other

1.05
0.45
1.83
1.82
8.20
9.9
0.78

(0.55-1.97)
(0.04-4.83)
(0.35-9.69)
(0.10-31.85)
(1.41-47.84)
(0.83-20.13)
(0.39-1.55)

Values in boldface are statistically significant.

*Analyses were adjusted for age, sex, household income, and parental education and for race in the overall analysis. There were 2,645 children with chronic medical conditions
other than food allergy (white, 982; black/African American, 650; Hispanic/Latino/Spanish, 764; and other, 249) and 1351 children with food allergy (white, 626; black/African
American, 239; Hispanic/Latino/Spanish, 305; and other, 181). Other chronic medical conditions include cystic fibrosis, sickle cell anemia, diabetes, arthritis, congenital heart
disease, other heart conditions, asthma, and anemia.