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. Author manuscript; available in PMC: 2024 Apr 1.
Published in final edited form as: J Allergy Clin Immunol Pract. 2023 Jan 28;11(4):1169–1176. doi: 10.1016/j.jaip.2023.01.020

Assessing Disparities in the Prevalence of Atopic Comorbidities Among Food Allergic Children

Anandu Dileep 1, Christopher Warren 2,3, Lucy A Bilaver 2, Ellen Stephen 1, Aame B Andy-Nweye 1, Susan Fox 1, Jialing Jiang 2, Pamela J Newmark 2, Annika Chura 5, Iman Abdikarim 4, Sai R Nimmagadda 2,3, Hemant P Sharma 4, Mary C Tobin 1, Amal H Assa’ad 5, Ruchi S Gupta 2,3,*, Mahboobeh Mahdavinia 1,*
PMCID: PMC10085831  NIHMSID: NIHMS1869383  PMID: 36720389

Abstract

Background

Previous studies have reported that Black children with food allergy (FA) have higher risk of atopic comorbidities than White children.

Objective

Our study sought to understand if disparities in the prevalence of atopic comorbidities among children with FA are driven by individual and community-level socioeconomic status (SES).

Methods

We analyzed data from a prospective, multicenter cohort investigating the natural history of pediatric atopy; the Food Allergy Outcomes Related to White and African American Racial Differences (FORWARD) study. A validated, multi-component area deprivation index (ADI) percentile score was tabulated by census block group for each subject’s home address. The association of ADI with atopic comorbidities in FA was assessed via multivariable regression analysis.

Results

Of the 700 children in this study, the mean ADI was 37.7 (95% CI: 35.6–39.7). Mean ADI was higher in children with asthma (43.3) compared to those without asthma (31.8), which remained significant after adjusting for race (p < .0001). Children with allergic rhinitis (AR) had a higher mean ADI (39.1) compared to those without (33.4); p = 0.008. ADI was associated with secondhand smoking, parents’ education, and household income. Black children had a higher risk for asthma after adjusting for ADI and SES-related factors.

Conclusion

The independent association of ADI with asthma and AR, regardless of race, suggests a role of neighborhood-level socioeconomic deprivation in the development of these conditions among children with FA. Black children with FA remained at higher risk for asthma after adjusting for SES-related variables, which can indicate an independent risk for asthma in these children.

Keywords: FORWARD, food allergy, race, asthma, allergic rhinitis, eczema, socioeconomic, disparities

Introduction:

Food allergy (FA) has become an increasingly prevalent condition across the pediatric population. Investigations from our group and others have identified significant racial disparities in FA phenotypes and outcomes1,2. Black children with FA are at higher risk for comorbid atopic conditions, more severe FA-related reactions resulting in emergency room visits, and increased sensitization to some common food allergens compared to their White counterparts1–4. The higher rates of asthma among Black children with FA is concerning as the presence of a coexisting food allergy can increase asthma morbidity in children5. Furthermore, these elevated rates of asthma may in fact drive higher rates of anaphylaxis to foods and FA-related emergency room visits among Black children4,6. Many of these observed differences in atopic disease outcomes are hypothesized to be related to access to care and other factors that are associated with living in communities with greater socioeconomic privation3. Therefore, it is important to understand whether these disparate rates of atopic comorbidities observed among Black children with FA, relative to their Non-Hispanic, White peers, are driven by differential environmental exposures, which are acknowledged to vary along with key indicators of individual and community-level socioeconomic status, regardless of race.

To that end, this study seeks to better understand the relationship between comorbidities related to FA (such as asthma, allergic rhinitis, and eczema) and various socioeconomic factors assessed at the respondent, child, household, and community levels. As a proxy for local socioeconomic conditions, we used the area deprivation index (ADI), a widely used, validated index, to characterize neighborhoods based on multiple socioeconomic determinants including income, education, employment, and housing quality7. ADI is a validated marker of neighborhood disadvantage, and it has been shown that residence within a community with high ADI can increase the risk for poor health outcomes8.

Methods:

We have utilized the data from our longitudinal, multi-center observational cohort of pediatric patients with FA known as Food Allergy Outcomes Related to White and African American Racial Differences (FORWARD).

Subjects:

The FORWARD study is a large, prospective, multicenter cohort study following pediatric patients who were recruited between ages 4 to 12 years. All FORWARD participants were diagnosed and evaluated in four tertiary care allergy and immunology clinics in Chicago, Washington DC, and Cincinnati9,10. The data used in the study were collected via several electronically administered surveys at the study intake as well as through routine chart reviews and clinical data extraction. FA was diagnosed based on history indicative of an IgE-mediated allergic reaction to foods plus a positive objective test for sensitization to that specific food (skin prick test and/or measurement of specific IgE to allergens). All children were evaluated for other atopic comorbidities including asthma, allergic rhinitis (AR), and eczema. Asthma was diagnosed per the latest diagnostic criteria by the Global Initiative for Asthma (GINA) guidelines11.

Socioeconomic Status (SES) Variables:

The ADI is calculated via a linear combination of seventeen census-derived indicator variables related to income, education, employment, and housing quality with the final percentile constructed from weighted factor score coefficients for each of its seventeen indicator variables. The ADI is calculated at the census block group level using aggregated data from the Census Bureau’s annual American Community Survey. Block groups are divisions of census tracts that typically contain between 600 and 3,000 people7. The most recent version of the ADI used in our study was updated in 201912 and approximates the median time of enrollment into the FORWARD cohort, which was established in 2017. Subjects’ residential addresses as reported via the intake survey were matched to United States Postal Service (USPS) deliverable parcels and converted to precise latitude and longitude coordinates using the US Census Bureau’s Geocoder. These residential addresses were assigned an ADI percentile corresponding to their respective Census Block Group. ADI is most frequently reported as a national percentile or a state-only decile. In either case, a higher ADI is associated with greater neighborhood socioeconomic disadvantage. For the purposes of this study, given that participants resided in multiple states, national percentiles were used and reported as a composite score ranging from 1 (least socioeconomically disadvantaged) to 100 (most socioeconomically disadvantaged). The mean ADI was compared across various household characteristics including annual household income and parental/guardians’ educational attainment, both of which were self-reported during the initial FORWARD intake survey. The survey also gathered information regarding the presence of a smoker in the household.

Statistical Analysis:

Mean ADI values were compared across participant and household characteristics using independent samples t tests, one-way ANOVA, and Pearson chi-squared analyses depending on the data type. Multiple logistic regression analyses modeled the probability of each atopic condition after adjustment for site, national ADI percentile, and participant race/ethnicity. Interaction terms between the continuous ADI percentile and the categorical race/ethnicity were specified to examine moderation effects. Multiple linear regression analyses were performed to analyze ADI in relation to household income, highest level of parental education, and exposure to secondhand smoking. Further analysis was conducted to see how secondhand smoke (SHS) exposure related to other social determinants. For all analyses, conventional two-sided p < 0.05 thresholds were applied to guide statistical inference.

Results:

The present study included 700 participants with FA younger than 12 years of age, 56% of whom were recruited from two diverse allergy clinics in Chicago, IL, 21% were recruited from the Washington DC region, and 22% were recruited from the Cincinnati, OH region. Among participants, 62% were male. The cohort included 51% non-Hispanic White, 37% non-Hispanic Black, and 12% Hispanic/Latinx children. The sample was approximately evenly distributed among those from households with annual incomes of <$50,000, $50,000-$150,000, and >$150,000. Additional descriptive characteristics of the sample are provided in Table 1.

Table 1:

Demographic and clinical characteristics in association with area deprivation index (ADI) in 700 children with food allergy enrolled in the FORWARD multisite study.

Variable (number) Mean ADI Ranking SD P-Value
CHILD GENDER
Male (N=388) 36.5 26.9 0.74
Female (N=236) 35.8 26.4
RECRUITMENT SITE
NU site (N=237) 33.4 24.5 < .0001α
RUMC Site (N=161) 45.2 26
CNH Site (N=146) 17.4 15.4
CCHMC Site (N=156) 55.2 26.3
CHILD RACE AND ETHNICITY
Non-Hispanic White Race/Ethnicity (N=321) 24.2 21.4 < .0001β
Non-Hispanic Black Race/Ethnicity (N=233) 51.5 26.2
Hispanic/Latinx Ethnicity (N=75) 41 23.2
ANNUAL HOUSEHOLD INCOME
<50K Income (N=177) 53.9 25.2 < .0001γ
50–150K Income (N=175) 40.5 23.8
>150K Income (N=202) 17.7 16.5
RESPONDENT EDUCATION
<Bachelor’s Degree (N=61) 49.2 27.6 < .0001δ
Bachelor’s Degree (N=311) 41.4 27.2
>Bachelor’s Degree (N=236) 25.6 21.7
COMORBID ATOPY
Asthma (N=229) 43.3 28.6 < .0001ε
No Asthma 31.8 24.5
Eczema (N=493) 36.3 26.9 0.75
No Eczema 35.4 26
Allergic Rhinitis (N=293) 39.1 27.3 .008η
No Allergic Rhinitis 33.4 25.8
SMOKER IN THE HOUSE *
Yes (N=89) 48.1 26.4 < .0001κ
No (N=604) 32.5 25.3
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Abbreviations: ADI - Area Deprivation Index, NU - Northwestern University, Ann & Robert H. Lurie Children’s Hospital of Chicago (Chicago, IL), RUMC - Rush University Medical Center (Chicago, IL), CNH - Children’s National Hospital (Washington, D.C.), CCHMC - Cincinnati Children’s Hospital Medical Center (Cincinnati, OH)

p-value was calculated by ANOVA in each category. Bonferroni test was used to compare the means between each two categories to evaluate corrected p-value for each comparison.

α:

The mean ADI was significantly higher at the CCHMC site compared to all other sites, RUMC participants had a higher ADI compared to the NU and CNH sites, while NU participants had a higher mean ADI compared to CNH.

β:

The ADI mean was significantly higher among Black participants compared to any other race/ethnicity and Hispanic/Latinx participants had a higher ADI compared to White participants.

γ:

The ADI mean was significantly higher among participants living in a household where annual income was < $50,000.00 compared to participants from households with higher annual incomes and participants with annual household income between $50,000.00 to $150,000.00 had a higher ADI compared to participants with an annual household income > $150,000.00.

δ:

The ADI mean was significantly higher among participants living in a household where highest level of parental education was less than a bachelor’s degree compared to participants from households with higher parental educational attainment and those from a household where highest level of parental education was a bachelor’s degree had a higher ADI compared to participants from households where parents had education beyond a bachelor’s degree.

ε:

The ADI mean was significantly higher among participants who had asthma compared to participants without asthma.

η:

The ADI mean was significantly higher among participants who had allergic rhinitis compared to participants without allergic rhinitis.

*:

Numbers in select rows do not add up as respondents did not specify yes or no for all questions in the intake survey.

κ:

The ADI mean was significantly higher among participants who had smoker in their household compared to participants without a smoker in their household.

Distribution of ADI in association with race/ethnicity and other SES measures:

The mean ADI across the analytic sample was 37.7 (95% CI: 35.6–39.7). The range of observed ADI values was [1–100]. Black children had the highest mean ADI of 51.5 compared to White (mean ADI of 24.2) and Latinx children (mean ADI of 41); p < .0001 for both comparisons, Table 1, Figure 1. The observed ranges of ADI values by race/ethnicity were [3–100], [1–98], and [1–98] for Black, White, and Latinx participants, respectively.

Figure 1:

Figure 1:

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A Kernel Density Plot demonstrating ADI distribution among White, Black and Latinx patients in the whole cohort where Black children had the highest mean ADI (51.5) compared to White (24.2) and Latinx (41) children.

As previously stated, participants in the FORWARD cohort were recruited from two sites in Chicago, IL, one site in Washington DC, and one site in Cincinnati, OH. The mean ADI was 45.2, 33.4, 17.4 and 55.2 for participants from Rush University Medical Center (Chicago), Lurie Children’s Hospital (Chicago), Washington DC, and Cincinnati, respectively (p < .0001) (Table 1).

We also examined ADI in relation to household income and highest level of parental education. The household income was inversely associated with ADI. Specifically, the highest mean ADI percentile was observed for participants with an annual household income of <$50,000 (mean ADI of 53.9) when compared to incomes of $50,000-$150,000 (mean ADI of 40.5) and >$150,000 (mean ADI of 17.7); p < .0001. A similar trend was seen with level of parental education where higher levels of education were associated with lower ADI. In households where highest level of education was less than a bachelor’s degree, the mean ADI was 49.2 as opposed to a mean ADI of 41.4 for those with a bachelor’s degree and a mean ADI of 25.6 for those with education beyond a bachelor’s degree (p < .0001).

Atopic comorbidities in association with ADI:

Among the 229 patients with asthma, the mean ADI was 43.3, as opposed to patients without asthma who had a mean ADI of 31.8 (p < 0.001). 293 patients were diagnosed with AR and had a mean ADI of 39.1, which was significantly higher than those without AR (mean ADI of 33.4); adjusted p = 0.008 (Table 1). ADI values did not significantly differ between patients with and without comorbid eczema. Regression analyses showed that both asthma and AR were associated with higher ADI even after adjusting for race/ethnic groups and recruitment site.

The mean ADI was 30.4 in children with no atopic comorbidities, while mean ADI was 33.7 among children with 1 comorbid condition, 33.8 in those with 2 comorbid conditions, and 44.7 with 3 comorbid conditions (p = .0001).

Secondhand Smoking (SHS) in association with ADI and other SES measures:

We found that the mean ADI was 48.1 among participants who lived in a household with a smoker, which was significantly higher than those who lived in households without any SHS exposure; mean ADI of 32.5 (p < .0001). When comparing the presence of SHS to race/ethnicity and other social determinants, additional significant trends were also observed (Table 2, Figure 2B). In our cohort, 21.8% of Black participants lived in households with reported SHS exposure, which was significantly higher than their White (3.2%) and Latinx (9.8%) counterparts; p < .001 for both comparisons. Among those with an annual household income of less than < $50,000, 20.2% of participants reported a smoker in the household in comparison to households with an income of $50,000-$150,000 (7.8%) and > $150,000 (4.4%); p < .001. As for respondent education, 26.5% of those with less than a bachelor’s degree reported there was a smoker in the house (p < .001). Among households where the highest level of education was a at least a bachelor’s degree, respondents less frequently reported a smoker in the house; 13% and 3.7% in those with a bachelor’s degree and those with greater than a bachelor’s degree, respectively.

Table 2:

Demographic and clinical characteristics in association with whether or not a smoker also resided in the household, reported as a percentage.

Variable (number) Smoker in House No Smoker Not Specified P-Value
CHILD GENDER
Male (N=388) 10.5% 72.4% 17.1% 0.87
Female (N=236) 10.2% 71.2% 18.6%
RECRUITMENT SITE
NU site (N=237) 9.0% 76.4% 14.6% < .001α
RUMC Site (N=161) 15.8% 68.4% 15.8%
CNH Site (N=146) 10.2% 84.9% 4.9%
CCHMC Site (N=156) 8.4% 54.5% 37.2%
CHILD RACE AND ETHNICITY
Non-Hispanic White Race/Ethnicity (N=321) 3.2% 79.3% 17.5% < .001β
Non-Hispanic Black Race/Ethnicity (N=233) 21.8% 62.1% 16.1%
Hispanic/Latinx Ethnicity (N=75) 9.8% 65.9% 24.4%
ANNUAL HOUSEHOLD INCOME
<50K Income (N=177) 20.2% 59% 20.7% < .001γ
50–150K Income (N=175) 7.8% 69.3% 22.9%
>150K Income (N=202) 4.4% 84.3% 11.2%
RESPONDENT EDUCATION
<Bachelor’s Degree (N=61) 26.5% 54.4% 19.1% < .001δ
Bachelor’s Degree (N=311) 13.0% 69.4% 17.6%
>Bachelor’s Degree (N=236) 3.7% 79.1% 11.2%
COMORBID ATOPY
Asthma (N=229) 13.4% 69.4% 17.2% 0.13
No Asthma 8.7% 73.4% 18%
Eczema (N=493) 10.6% 71.9% 17.6% 0.88
No Eczema 9.1% 72.9% 18.2%
Allergic Rhinitis (N=293) 11.6% 71.6% 16.8% 0.5
No Allergic Rhinitis 9.1% 72.4% 18.5%
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Abbreviations: NU - Northwestern University, Ann & Robert H. Lurie Children’s Hospital of Chicago (Chicago, IL), RUMC - Rush University Medical Center (Chicago, IL), CNH - Children’s National Hospital (Washington, D.C.), CCHMC - Cincinnati Children’s Hospital Medical Center (Cincinnati, OH)

p-value was calculated by ANOVA in each category. Bonferroni test was used to compare the means between each two categories to evaluate corrected p-value for each comparison.

α:

A significantly higher percentage of participants at the RUMC site reported the presence of a smoker in the household compared to all other sites, a higher percentage of CNH participants reported a smoker in the household compared to the NU and CCHMC sites, and NU participants had a higher percentage compared to CCHMC.

β:

A significantly higher percentage of Black participants reported the presence of a smoker in the household compared to their White and Hispanic/Latinx counterparts, and a higher percentage of Hispanic/Latinx participants reported a smoker in the household compared to White participants.

γ:

A significantly higher percentage of participants living in a household where annual income was < $50,000.00 reported the presence of a smoker in the household compared to participants from households with higher annual incomes and participants with annual household income between $50,000.00 to $150,000.00 had a higher percentage compared to participants with an annual household income > $150,000.00.

δ:

A significantly higher percentage of participants living in a household where highest level of parental education was less than a bachelor’s degree reported the presence of a smoker in the household compared to participants from households with higher parental educational attainment and those from a household where highest level of parental education was a bachelor’s degree had a higher percentage compared to participants from households where parents had education beyond a bachelor’s degree.

Figure 2B:

Figure 2B:

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A Kernel Density Plot demonstrating ADI distribution among households with a smoker, without a smoker, and not specified where exposure to secondhand smoking was associated with higher ADI.

Effect of ADI on the association of race with comorbidities:

Our models showed Black children were significantly more likely to have asthma compared to White children even after adjusting for the ADI and recruitment site (Table 3); Odds Ratio (OR) (95% CI) = 2.76 (1.77–4.29). Asthma prevalence among Latinx children was not significantly higher than White children after adjusting for ADI and site [OR (95% CI) = 1.23 (0.69–2.22)]. The adjusted model also showed that Black children were more likely to have AR [OR (95% CI) = 2.50 (1.63–3.85)] compared to White children, though this was not the case for Latinx children [OR (95% CI) = 1.45 (0.83–2.52)]. No significant racial differences were noted among children with eczema after using the adjusted model. When assessing for moderation between ADI and race, there was no statistical evidence to suggest that ADI moderates the link between race and asthma prevalence. This null association was evident for both Black and Latinx children when compared to their White counterparts. However, there appears to be evidence for moderation of ADI on the link between race and AR in Latinx children [OR (95% CI) = 0.969 (0.945–0.995)] when compared to White children. Statistically significant findings for moderation between ADI and race were not observed in Black children with AR [OR (95% CI) = 0.987 (0.971–1.002)], and Black children had the highest observed rates of AR across the full range of observed ADIs.

Table 3:

Odds Ratios for different atopic comorbidities among Black and Hispanic/Latinx children (compared to Non-Hispanic White children).

Atopic Disease Race/Ethnicity Odds Ratio 95% Confidence Interval
ASTHMA
Non-Hispanic Black 2.76 1.77 – 4.29α
Hispanic / Latinx 1.23 0.69-2.22
ECZEMA
Non-Hispanic Black 1.13 0.65-1.96
Hispanic / Latinx 0.78 0.40-1.52
ALLERGIC RHINITIS
Non-Hispanic Black 2.50 1.63 – 3.85β
Hispanic / Latinx 1.45 0.83-2.52
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α, β:

Black children had higher odds of asthma and allergic rhinitis compared to White children after conducting multiple logistic regression analyses and adjusting for site, national ADI percentile, and participant race/ethnicity.

Discussion:

We observed a significant difference in ADI distribution between children with and without atopic comorbidities. Children with FA who have asthma and AR were more likely to live in higher ADI (more deprived) areas. ADI considers multiple socioeconomic determinants including income, education, employment, and housing quality12. This finding indicates that socioeconomic deprivation may affect the prevalence of asthma and AR among children with FA. Our data echoes what has been seen with previous literature regarding the impact of poverty on asthma in children13. In one study involving over 100,000 children (the National Survey of Children’s Health), the prevalence of asthma was higher in groups with relatively low employment rates, income, and insurance coverage13. Similarly, another study involving subjects in New York City noted that the communities with the most cases of asthma corresponded to areas with higher concentrations of impoverished minorities, low-income households, and public housing14. Furthermore, we found a higher ADI among those who had more than three comorbid atopic diseases. It is possible that the constellation of environmental exposures that are experienced by individuals living in poverty plays a role in the development of atopy. This places children from deprived neighborhoods at risk and highlights the urgent need for programs to address the needs of these children. The link between higher ADI and asthma risk is particularly important as patients with comorbid asthma and FA, especially those with allergy to more than one food, have been reported to have increased hospitalizations, emergency department visits, and use of oral steroids5. Likewise, greater socioeconomic disadvantage is shown to be linked to higher rates of complications among patients with asthma15.

Proposed mechanisms through which these community-level factors influence health outcomes include the impact of physiologic stress pathways (hypothalamic-pituitary-endocrine pathways)15 on different systems. At the individual patient level, psychosocial stress has been positively correlated with respiratory symptoms, poor asthma control, poorer asthma quality of life, and decreased adherence with prescribed medications15,16. In the case of children, caregiver stress level is another important factor to consider. A higher ADI is associated with numerous social stressors, and a greater degree of stress may provoke more parental tobacco use17, thereby increasing SHS exposure among their children18. Analysis of our cohort revealed a higher mean ADI among patients who lived in a household with a smoker (Figure 2B). A greater proportion of respondents with lower annual household income (< $50,000) and educational attainment (less than a bachelor’s degree) also reported a smoker lived in the household. The harmful effects of SHS for all patients with respiratory disease including asthma and allergies has been well described19. SHS exposure increases the risk for asthma, asthma exacerbations, wheezing, and reduced lung function20. Therefore, the observed higher SHS exposure along with the higher rate of asthma in FA children impacted by poverty presents a challenge that warrants further attention.

It is possible that the observed link between ADI and risk of AR in our study is linked to exposure to triggers such as air pollutants and indoor allergens. A study involving various subjects from Northern Europe found that the development of allergic rhinitis was associated with increased exposure to an urban environment during childhood21. Air pollution has been causally linked to airway inflammation and a higher prevalence of allergic airways diseases22,23. Besides air pollutants, indoor allergen levels have been found to be elevated in urban households living in low-income areas with higher ADIs relative to suburban areas24,25. Exposure to high levels of these indoor allergens such as cockroach are especially detrimental in children with comorbid asthma26–28. An increase in exposure to cockroach and dust mite allergens may also provoke cross-sensitization and development of shellfish allergy in these high-risk atopic children10,29.

The distribution of observed household-level ADIs (Figure 1) estimated among our sample represents a wide range of SES, as also evidenced by the even distribution of participants with regard to parental education and annual family income (Table 1, Figure 2A). This places our study in the right position to investigate the question of whether the association between race and increased atopic comorbidities in FA is impacted by the socioeconomic conditions. It is noteworthy, as detailed in Table 1, that there is a significant association between our internal survey-based measures (annual household income and education) and ADI, which supports the internal validity of our findings. Nonetheless, the higher odds of asthma and AR among Black children remained significant after adjusting for all the included SES variables (Table 3). The prevalence of asthma among Black patients with FA in our cohort is consistent with Black children being disproportionately affected by asthma in general30. To our knowledge, this is the first study showing an independent association between pediatric asthma risk and Black race in children with FA after adjusting for a variety of household and community-level socioeconomic factors. This is of the utmost importance as Black children tend to also experience up to 30% higher asthma-related deaths than White children31.

Figure 2A:

Figure 2A:

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A Kernel Density Plot demonstrating ADI distribution among households with annual incomes less than $50,000.00, between $50,000.00-$150,000.00, and greater than $150,000.00 where children from families with lower annual income had the highest mean ADI compared to other groups.

For Black children living in higher ADI neighborhoods, it is important to consider that ADI does not address all potential barriers to accessing healthcare. Specifically, transportation barriers to health care are more common for many vulnerable populations32. When considering some of the sites involved in this study, the main allergy and immunology clinics are located in close proximity to the main hospital campus with some additional clinics located in other suburbs, outside of the city boundaries33–35. However, Children’s National Hospital (CNH) has multiple neighborhood-based primary care sites within the city where patients can see allergy and immunology specialists. CNH also utilizes mobile health services, which not only provide children with medical care but also offers family crisis management and support36. While ADI does not consider access to healthcare, it is necessary to address this issue to ensure food allergic children with atopic comorbidities are adequately treated regardless of their place of residence.

While Black and Latinx participants’ ADIs were more evenly distributed across ADI national rankings with a slight skew towards higher deprivation scores (poorer socioeconomic conditions), White participants had a marked trend towards lower deprivation scores (better socioeconomic conditions). This could have potentially affected our ability to investigate our findings among White children with FA from poor neighborhoods and is a limitation of our study. Similarly, when looking at mean ADI in relation to recruitment site, the mean ADI was lowest for Washington DC and highest for Cincinnati, OH. This may be indicative of a lack of participants with FA from higher ADI neighborhoods in Washington DC and lower ADI neighborhoods in Cincinnati, OH, which is also a limitation of our study. Additionally, it is important to point out that the Latinx population is not homogenous. For example, in Chicago, the 2017 Census shows that a majority of the Latinx population is of Mexican descent (73%), followed by Puerto Rican (12.5%) and Cuban (1%) descent37. And in Washington D.C, the population consists of individuals of Salvadoran (25.1%), Dominican (11.6%), Mexican (11.6%), Puerto Rican (10.8%), Colombian (6.5%), and Honduran (5.1%) descent38. Thus, the inability to assess how ancestry may impact the diverse Latinx population was a limitation of this study.

Our findings suggest a role for neighborhood-level socioeconomic deprivation in the prevalence of asthma and AR among children with FA. Furthermore, Black children were found to be at higher risk for asthma and AR independent of SES related factors.

Highlights Box.

1. What is already known about this topic?

Racial disparities in food allergy phenotypes and outcomes have been reported. Specifically, Black children are at higher risk for comorbid atopic conditions. This may be related to factors associated with greater socioeconomic privation.

2. What does this article add to our knowledge?

Neighborhood-level socioeconomic deprivation plays a role in the development of asthma and allergic rhinitis among children with food allergy. Black children were at higher risk for these conditions independent of socioeconomic related factors.

3. How does this study impact current management guidelines?

Providers taking care of children with food allergy should screen for asthma and allergic rhinitis more diligently among Black patients. They should also engage patients’ parents to understand socioeconomic obstacles a family may be facing.

Acknowledgments:

FORWARD (NIH number: 1R01AI130348-01A1)

MM is also supported by 1R03TR004005 from NIH

Funding Statement:

FORWARD was supported by the National Institute of Health (Grant Number: 1R01AI130348-01A1).

Disclosure Statement:

Dr. Gupta, Mahdavinia, Warren, Bilaver and Assa’ad report other research support from the National Institutes of Health and, Food Allergy Research & Education (FARE). Dr. Mahdavinia is also supported by the research grants from Optinose Foundation, Brinson Foundation and The Institute for Translation Medicine in Chicago. Dr. Bilaver receives research grant support from Rho, Genentech, National Confectioners Association, Novartis, and Before Brands Inc. Dr. Warren reports other research support from the Sunshine Charitable Foundation. He reports receiving honoraria for development of CME review articles on epidemiology from the American College of Allergy, Asthma, and Immunology and for workshop delivery regarding patient-reported outcomes research from the American Academy of Allergy, Asthma, and Immunology.

The authors whose names are listed immediately below certify that they have NO other affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.

Abbreviations

FORWARD

Food Allergy Outcomes Related to White and African American Racial Differences

ADI

Area Deprivation Index

SES

Socioeconomic Status

FA

Food Allergy

AR

Allergic Rhinitis

GINA

Global Initiative for Asthma

USPS

United States Postal Service

SHS

Secondhand Smoke

RUMC

Rush University Medical Center

CNH

Children’s National Hospital

CCHMC

Cincinnati Children’s Hospital Medical Center

OR

Odds Ratio

CI

Confidence Interval

Footnotes

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References

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