Preventing Anaphylaxis in College Students With Food Allergies

Food allergy affects up to 11% of college-aged students, with the most common allergens being shellfish, peanut, treenut, finfish, and milk/dairy.¹ Fatal food-related anaphylaxis is rare; however, an age-related predisposition to fatal outcomes has been suggested in the second and third decade.² Recently, a first semester college student, who had a known peanut allergy, ate food at a campus event that he did not realize contained peanuts.³ He sensed he needed epinephrine, but his self-injectable epinephrine (SIE) was in his dorm room. After he returned to his dorm room, he self-administered epinephrine, but his symptoms continued to worsen. The residence staff then took him to the hospital by car. On the way to the hospital, the student’s symptoms continued to progress and 911 was called.³ Paramedics intercepted and attempted to assist the student, but he unfortunately died before arrival to the hospital.³ This case highlights preventable fatal-food anaphylaxis and the special needs of college students. College is a unique time for many students as they are newly living independently without direct parental supervision.^4,5 Students need to maintain their emergency medications and make safe food choices on their own while balancing academic and social pursuits.^4,5

Many college students experience allergic reactions, with 42% to 63% of students with food allergies reporting an allergic reaction to food while enrolled in college.⁴ College dining halls are a site for potential allergic reactions; however, only 12% to 45% of students report that their dining halls always label allergens.^4,6 Of students who reported a reaction in their dining halls, 56% had symptoms consistent with anaphylaxis.⁴ A follow-up survey was conducted at the University of Michigan 6 years after the school had implemented food allergy dietary and nutritional support including food labeling in the dining halls.⁵ Among food-allergic students, rates of practicing strict allergen avoidance and making sure food preparers were aware of allergies were still under 50%.⁶

Only 40% to 50% of students with food allergies always avoid the foods they are allergic to.^4,6 Students with food allergy often engage in risky food behaviors due to social pressure.⁵ Concerns of missing out on events are common, and asking staff about allergens can feel embarrassing.⁷ Furthermore, students develop disclosure fatigue as they become tired of talking about their allergy.⁶ Although allergists advise that patients with food allergies always carry SIE, only between 7% to 21% of students with food allergies report that they always carry their devices.^2,4,6 Barriers to carrying SIE in adolescence include the inconvenience and difficulty of the size, fear of administering the SIE in the event of a reaction, and being seen as different.⁷

Because food is an integral part of everyday life and social interactions, food allergies can significantly affect social interactions for college students and contribute to social isolation.⁵ Anytime food is served, a single mistake can cause severe illness or death. Therefore, managing food allergies can lead to substantial stress, impaired quality of life, and financial burden.⁵ Students also worry about how allergy symptoms and treatment related to food allergy could affect their schoolwork.⁵ Moreover, obtaining allergen-free foods can be difficult given the variability in safe food practices in dining halls and requires constant vigilance.⁵

Educating nonallergic students has a role in decreasing morbidity from food allergies. In the study of students at the University of Michigan after they had instituted their food allergy program, nonallergic students reported increased awareness of allergen content labeling in the dining hall and the need for allergen avoidance for students with food allergies.⁶ Further education of nonallergic students could help support students with food allergies as allergic students may feel more comfortable and empowered to disclose their food allergies and carry SIE.

Efforts to prevent risky behaviors include thoughtful planning and education before students leave for college.⁵ When choosing colleges, students should be aware and ask about food allergy accommodations at the schools. Accommodations provided by colleges range from having nothing to training dining services staff members on the basics of food allergies and ensuring that campus emergency responders carry epinephrine.⁸ Some colleges have dormitory rooms with small kitchens and give students with food allergies priority access to these rooms with a physician request in order for students to prepare their own foods. The Food Allergy Research and Education (FARE) Food Allergy College Search is an online tool that allows students to search dining options, housing accommodations, emergency services, and other programs at colleges.⁸ The FARE Food Allergy College Search database is composed of self-reported information from participating colleges or information gathered from the schools’ websites.⁸ Contacting colleges directly is also beneficial. Table I shows the number of colleges with specific allergy-friendly practices.⁸ Of 1200 colleges included in the database, 66% have allergy-friendly stations in the dining hall and 7% stock undesignated epinephrine for emergency response.⁸ Despite food allergy accommodations being offered at many colleges, none of these accommodations have been studied to see if they are effective in preventing food allergy symptoms.

TABLE I.

Food allergy practices at colleges from the Food Allergy Research and Education College Search (N = 1200)

Allergy-friendly practice	Percentage of colleges (n)
Allergy-friendly station in the dining hall	66 (789)
Cross-contact procedures in made-to-order areas in the dining hall	94 (1132)
Ingredient information available online for the dining hall	59 (705)
Preorder meals	90 (1078)
Roommate accommodations	22 (263)
Stock, undesignated epinephrine available for emergency response	7 (79)

Physicians can help by addressing the potential social factors students may face in order to develop a plan on how to handle the college environment.⁵ The plan for the student can include proactively developing a relationship with accommodative services, communicating with dining services to make sure safe food options are available, developing a plan when safe food is unavailable, discussing the possibility of disclosure fatigue, and preparing for social pressures of college.⁵ Additional counseling could center on improving food allergy knowledge, strategies to carrying SIE,⁹ the cost and varying insurance coverage of SIE, and the importance of annual follow-up with their physicians. In the case of the college student, it is unknown whether having SIE available immediately could have saved his life. Nevertheless, delayed use of SIE is a risk factor for fatal food anaphylaxis, and not carrying an SIE is a modifiable risk factor to prevent fatality.² Future studies could address the most effective interventions to support college students with food allergies.

In summary, understanding and addressing the college environment may help clinicians prepare high school students with food allergies for college life. Understanding student barriers including the inconvenience of carrying SIE, social pressures, and feelings of isolation in addition to accommodations provided by schools may help prevent nonfatal and fatal allergic reactions in college students with food allergies.