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Peanut Allergy Dietary Advice for Adults
Written by the Food Allergy Specialist Group (FASG) of The British Dietetic Association 2020.
Signs and symptoms of peanut allergy
Symptoms can occur within minutes or up to 2 hours after eating peanuts or foods containing peanuts. They range from mild to severe and may include:
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Sudden onset itchy eyes, ears, runny nose and sneezing
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dry repetitive coughing
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itching or tingling of the lips, tongue or throat
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red, raised itchy rash (hives) on face or body
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stomach ache, nausea or vomiting
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swelling of face, eyes, lips, tongue or throat
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difficulty swallowing or talking
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difficult or noisy breathing
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drop in blood pressure that can lead to dizziness, collapse or loss of consciousness.
Everyone has different reactions, so you should have been given specific advice on how to deal with an allergic reaction by your Doctor or a member of the allergy team. You should also be given a written emergency plan.
It is difficult to predict who will have a severe (anaphylactic) reaction but the risk tends to be higher in people who have asthma. However, anyone who has a peanut allergy has the potential to have a severe allergic reaction even if previous reactions have been mild. The amount of peanut needed to cause a reaction will also vary; even trace amounts of peanut can cause severe reactions in some people.
Some people might be prescribed an adrenaline auto-injector (AAI) (such as Epipen, Jext or Emerade). If you have been prescribed on of these devices, make sure you know how to use it, and also that you have it with you at all times. Some people are prescribed one AAI and others two; if you have been given two adrenaline devices you must carry both of them with you.
Diagnosis
It is important that a peanut allergy is diagnosed by a healthcare professional with the right training. They will ask questions about the history of any allergic reactions and may perform tests. The type of tests will depend on the type of reactions and the symptoms experienced.
Skin prick tests or blood tests that measure ‘specific IgE antibodies’ may be used to help with the diagnosis. These test results can be difficult to interpret without an allergy specialist. Sometimes, a food challenge (where increasing amounts of the suspected food are given and symptoms monitored) may be needed to make a diagnosis. This will only be carried out in a safe hospital setting.
Some companies offer food allergy or intolerance tests that measure IgG antibodies. These are not a safe or reliable way of diagnosing nut allergies. Other tests such as hair analysis, kinesiology testing and vega testing have also been found to be unreliable and have no scientific basis, and therefore should not be used.
Will peanut allergy ever go away?
We know that about 20% (1 in 5) of peanut allergic children will grow out of their allergy. However, we really do not know much about adult peanut allergy, or how many years you are likely to have this problem. It could be life-long; so you should not try to reintroduce nuts into your diet without medical guidance or supervision.
Should other nuts be avoided?
We know that 30% (1 in 3) of peanut allergic people will react to one or more tree nuts.
If you are avoiding tree nuts but don’t know whether you can eat them or not, you should discuss this with your Doctor or the allergy team. Many people with peanut allergy can eat all tree nuts, but you will need to have allergy tests and might need to have a food challenge in hospital to find out whether you can eat some or all tree nuts. So if you are currently avoiding all nuts, it is very important that you do not try introducing tree nuts into your diet without medical supervision.
If you have been advised by your Doctor that it is safe to eat some or all tree nuts, we recommend that they are only eaten if you are confident that they are not contaminated with peanut and they are only eaten at home with emergency medication to hand.
What about...?
Chestnut, water chestnut, coconut, palm nuts, nutmeg and butternut squash: Despite all containing the word “nut”, none are related to peanuts. Therefore, they should not be avoided unless they are known to cause a problem.
Shea nut
Shea nut butter and oil are mostly found in moisturising creams, toiletries and cosmetics but are increasingly found as an ingredient in chocolate-based confectionery. They contain minimal protein and the risk of allergic reactions to products containing shea nut is very low. Shea nut is a tree nut so if you can eat tree nuts you do not need to worry about avoiding these products, but if you have eczema it is probably sensible not to use skin creams containing shea nut butter or tree nut extracts.
Sesame seeds and pine nuts
These seeds share some similar allergens to peanut but there is no need to avoid them unless you have also been diagnosed with a sesame or pine nut allergy. Usually in adults, sesame is a stand-alone allergy and does not involve reactions to other foods.
Other Legumes (pulses)
Peanuts belong to the legume family, which includes: peas, kidney beans, chick peas, white beans, baked beans, bean sprouts, lentils, soya beans (including soya products), lupin and fenugreek. The vast majority of people with a peanut allergy can eat all legumes and none of them should be avoided unless you have specifically had reactions to them. Usually people with a legume allergy react primarily to lentils, chick peas and kidney beans, and often can eat peanuts and other beans without any difficulties. A small number of adults with peanut allergy (particularly those of South Asian decent) may react to another legume. If you are not sure whether you also need to avoid legumes, discuss this with your Doctor or allergy team, before cutting them out of your diet.
Lupin and fenugreek are both legumes which might be found in small quantities in foods. Lupin seed flour may be used instead of wheat or soya flour in French breads, biscuits, cakes, pastry, pancakes, pizza, pasta, wheat and gluten free foods and some vegetarian products. Lupin is only used as an ingredient in a few UK foods. It is more widely used in mainland Europe, Brazil and the Middle East.
Fenugreek is a spice often present in curries and curry spices mixes. Both of these legumes may be more likely to cause reactions in people with a peanut allergy, so if you are having reactions but know you have not eaten peanuts, check the ingredients list of any foods you have had reactions to.
Nut Oils
Refined peanut oil has had the protein removed, which is the part of the nut that causes allergic reactions. Therefore, it is highly unlikely to cause a reaction in the majority of peanut allergic people. Some medicines e.g. Abidec baby vitamins contain refined peanut oil. Whilst the risk of an allergic reaction is very low, the Committee on Safety of Medicines has recommended that patients known to be allergic to peanuts should not use medicines containing peanut oil.
Unrefined, crude or cold pressed peanut oil (also called groundnut oil) may contain small amounts of nut protein and is more likely to cause reactions so should always be avoided. Unrefined peanut oil is most commonly found in Indian or Oriental food products in dishes such as curries or stir-fries.
Note: In the UK, both refined and unrefined peanut oil must be labelled as containing peanut. However, it is not a legal requirement for manufacturers to say whether their peanut oil is refined or unrefined. Therefore, the safest approach is to avoid all foods that contain peanut or groundnut oil.
Vegetable oil and products containing vegetable oil that are sold in the UK must state if they contain any peanut or nut oil. Therefore, all products containing vegetable oil are safe to eat unless peanut or tree nuts are listed in the ingredients.
Checking food labels
European Union (EU) food allergen labelling law requires that common food allergens used as ingredients or processing aids must be declared on the packaging or at the point of sale. The list of 14 common food allergens includes tree nuts, peanuts, lupin and sesame. Any products that contain peanut should use the term ‘peanut’ on the ingredient label and those containing tree nuts should list each type of nut (e.g. cashew, walnut, almond etc).
These laws apply to all packaged and manufactured foods and drinks sold throughout the EU. They also apply to foods sold loose (e.g. from a bakery, delicatessen, butcher or café) and foods packed or pre-packed for direct sale (e.g. café, sandwich bar, food outlet, market stall, some catering products). If you travel outside the EU, be aware that labelling laws are different so check ingredients carefully.
For pre-packed products (e.g. made in a factory) allergens must be listed in one place on the product label (i.e. in the ingredients list) and highlighted (e.g. in bold or underlined).
Example of food label:
Satay Sauce:
Ingredients: water, peanuts (28%), coconut milk (7%) (coconut extract, water, stabiliser (guar gum, sodium carboxy methyl cellulose) emulsifier (sucrose esters of fatty acids), brown sugar, Soy Sauce (water, soya beans, wheat, salt), garlic, tamarind extract (1.5%),
lemongrass (1.5%), galangal (1.0%), sesame seed oil, modified maize starch, acidity regulator (lactic acid), salted chilli (chilli, salt), sunflower oil.
Allergy Advice: For allergens, see ingredients in bold.
For more information on food allergy labelling go to NHS Food allergy information
There are different rules for:
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foods which are pre-packed on the same site where they are sold (pre-packed for direct sale) such as in a café, sandwich shop, deli or food outlet preparing food in their own kitchen. For these foods, allergen information has to be provided either in writing or verbally. However, the law is changing and from Autumn 2021 labelling with the full list of ingredients will be required.
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foods sold without packaging such as in a bakery, café or pub. For these foods, allergen information has to be provided either in writing or verbally. If provided verbally, the business must be able to provide further written information if requested (in the UK only).
Food Allergy Notice: If you have a food allergy please ask a member of staff for further information. Thank you
Be aware that food manufacturers change their ingredients from time to time e.g. ‘new improved recipe’. Therefore, it is always safer to check the ingredients every time you buy.
May contain…’ or ’Made in a factory…’ labelling
These warnings are used by food manufacturers to highlight a possible risk of an otherwise nut free product being accidentally contaminated by nuts during manufacturing. There is currently no law to say how or when this type of labelling should be used but it appears on a wide variety of products. The way these statements are worded does not indicate their level of importance, e.g, ‘not suitable for….’ does not mean there is a greater risk of contamination than ‘made in a factory….’. Tolerance to foods with a ‘may contain’ labelling does not always mean that trace amounts of allergen are tolerated.
It is important to take these warnings seriously and consider the following points:
Just because a particular food with a nut warning has been eaten safely in the past, does not mean that it will always be safe; it may contain nut traces next time. Recipes and manufacturing processes can change.
All nut warnings should be treated with the same level of risk regardless of the wording used.
Patients may be more sensitive to nut protein if they are unwell, have been doing strenuous exercise or drinking alcohol, so having a nut trace during these times is more risky.
Sweet and savoury snacks (e.g. cakes, biscuits, cereal bars, and crackers), confectionary and breakfast cereals are the foods most likely to be contaminated with peanuts and should be avoided if they have a ‘May contain’ warning.
Chocolate and chocolate covered items pose a higher risk of nut contamination because chocolate dripping off one product may be used on another during manufacturing. Therefore, chocolate with nut warnings should always be avoided (lists of peanut free or all nut free
products are available from chocolate manufacturers).
The safest approach is to avoid all foods with “may contain” nut warnings. However, if a food with a nut warning is to be eaten the following advice should always be followed:
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Always have in-date emergency medication to hand
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be within easy reach of a phone or mobile that has charge and reception
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only eat if someone is with you who can help if a reaction occurs
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avoid if in a remote location, far from emergency services
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avoid if unwell or asthma is not well controlled
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avoid after strenuous exercise or drinking alcohol
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avoid if you have had a previous anaphylactic reaction to nut traces or “may contain” products.
Discuss your approach to managing “may contain nut” products with your Dietitian or allergy team as they can give you specific advice.
Allergy Alerts
Sometimes food products have to be withdrawn or recalled if they pose a risk to customers. This may be because the allergy labelling is missing, wrong or if there is any other food allergy risk. You can get allergy alerts from the Food Standards Agency website or when
you subscribe to a free email or SM text message alert system. Subscribe to get food and allergy alerts.
Alternatively, you can view product alerts online. Sign Up for Allergy Alerts.
For more information on food allergy labelling go to NHS Food allergy.
Cross contamination
Cross contamination is a risk for people with a nut allergy. It occurs when a nut free food accidentally comes into contact with nut protein during storage, manufacturing or food preparation. Even tiny traces of nut can cause an allergic reaction if eaten. Skin contact with a contaminated item may cause a local skin irritation but will not cause a severe (anaphylactic) reaction.
Examples of Cross Contamination
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Using the same spoon to serve peanut containing and peanut free dishes (e.g. ice cream), or using the same cooking pan or oil previously used to cook a nut based meal (e.g. Chinese or Indian restaurant or takeaway food).
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Eating only the raisins from a packet of nuts and raisins.
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Food touching at a buffet, deli-counter, self-service salad bar or on a barbeque (e.g. satay chicken next to a plain burger).
Tips to Reduce Cross Contamination
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Take extra care with hand washing and cleaning of food preparation areas and equipment. Wipe down surfaces with hot soapy water.
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Always use clean dishes and cutlery. Never use the same knife for peanut butter, margarine and jam. Use separate labelled containers for the allergic person if other people in the household are eating peanut butter or nuts.
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Consider having one agreed place in the kitchen where nuts are prepared and consumed or make your home a nut free zone.
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Don’t drink from cups used by other people that may have been eating nuts.
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Avoid kissing or holding hands with someone who has eaten nuts until they have thoroughly cleaned their hands, face and mouth.
Common peanut containing foods to avoid
Please note: this is not an exhaustive list – always check labels.
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Breakfast cereals: crunchy nut cornflakes, muesli or granola with nuts, honey nut cereals, nut Cheerios™, Krave™.
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Cereal bars: Tracker™ bar, Jordans™ bar, Eat Natural™, Nakd™ and Trek™ bars.
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Bread & crackers: Speciality breads topped with or containing nuts (e.g. Peshwari & Kashmiri naan bread).
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Biscuits, pastries and cakes: peanut cookies, boasters, chocolate brownies, Dundee or Christmas cake, Stollen cake).
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Chocolates and Sweets: Snickers™, Reese’s™ peanut butter cups, Revels™, peanut M&Ms™, Celebrations™, Quality Street™, Roses™, speciality chocolates or mixed selections with praline, nut brittle, halva.
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Desserts, ice cream and cheese: Snickers™ ice cream, ice cream sundae topped with nuts, ice cream scooped from ice cream counter where risk of cross contamination is high, Crediou or Rambol cheese coated in nuts.
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Take-away/ready meals: Indian, Chinese, Thai, Indonesian, Middle Eastern, and African dishes - many are contaminated with or contain nuts or unrefined nut oils or sauces thickened with peanut flour (e.g. bhajis, samosas, tikka and korma curries, spring rolls, stir fries with
cashew or peanut, chicken satay, pad Thai, couscous or tagine with roasted almonds or pistachios).
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Vegetarian foods: nut cutlets, veggie burgers, nut roast.
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Salads: nut-based salads, peanut sprouts and peanut shoots - now being sold in some supermarkets.
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Soup, sauces & spreads: peanut soup, satay sauce, Chinese and curry sauces (e.g. hoi sin, korma), pesto (often contains cashew or other nuts as well as pine nuts), peanut butter.
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Savoury snacks: peanuts, mixed nuts and raisins, Bombay mix, trail mix, Bamba snacks, Chinese rice crackers, pop corn cooked in ground nut oil.
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Drinks: nut flavoured milk shakes, peanut punch.
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Oils: Peanut oil, groundnut oil, Arachis oil.
Suitable foods and foods to avoid
The following tables provide a list of foods that are usually nut free and those that sometimes contain nuts and should always be checked. This list may not be complete as products change, so you must always check the ingredients list on the package. Remember to discuss with your Dietitian how to approach ‘may contain’ labelling.
Suitable foods and foods to avoid
Type |
Nut Free Foods |
Foods that may contain nut |
Milk and Dairy Products |
Cow/goat/sheep milk. |
Ice cream, ice cream wafers. |
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Soya/rice/coconut/oat milk |
Flavoured milk. |
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Plain yoghurts, fromage frais. |
Cheesecake |
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Fresh cream. |
Cheese spreads |
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Plain cheese, plain cream cheese & cottage cheese. |
Speciality and loose unpackaged cheese. |
Meats and fish |
Fresh or frozen unprocessed meat or fish. |
Indian, Chinese, Thai, Indonesian, Mexican, Middle Eastern, African dishes. |
|
Plain tinned fish e.g. tuna, salmon, sardines etc. |
Processed meat and fish dishes (e.g. pate, sausages, burgers, breaded chicken, fish fingers, meat pies & pastries, coronation chicken, and meat or fish in sauces or marinades). |
Breakfast Cereals |
Plain breakfast cereals without nut warnings e.g. Weetabix™, cornflakes, porridge oats, Shredded Wheat™ etc. |
Breakfast cereals (e.g. fruit & fibre, muesli, granola, oat crunch and flavoured cereals). |
Breads, pastries, cakes and biscuits |
Plain breads & rolls (white, brown or wholemeal). |
Loose products (e.g. from bakery or deli) for cross contamination. |
|
Plain bread products. e.g. pitta bread or baguettes. |
Naan bread, speciality breads. |
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Cream crackers. |
Bread sticks, rice cakes, crackers. |
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Plain cakes and biscuits with no nut warnings. |
Cereal/muesli bars, flapjacks. |
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Home-made or purchased bread, cakes and biscuits known to be nut free. |
Fruit cakes, and other Middle Eastern cakes and pastries. |
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*Check for lupin if relevant |
Sponge cakes, pastries, pies, gateaux, cookies and biscuits. |
Fruit, vegetable and pasta |
Fresh, plain frozen, stewed, tinned or dried fruit and vegetables. |
Mixed salads, rice/pasta/noodle salads, coleslaw and fruit dishes. |
|
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Vegetarian dishes (e.g. Veggie burgers, cutlets & sausages, pate). |
|
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Pasta dishes with pesto sauce (may contain cashew) and nut fillings in tortellini and ravioli |
Desserts, sweets and chocolate |
Jelly. |
Chocolate, fudge or toffee bars. |
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Milk puddings, custard, egg custard, rice pudding. |
Mixed chocolate selections |
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Sweets known to be nut free e.g. boiled sweets. |
Asian, Greek, Turkish, Middle Eastern sweets. |
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Chocolate guaranteed to be nut free. |
Instant desserts, trifle toppings, mousse, ice cream and ice lollies, meringues, pavlova. |
|
Home-made or purchased desserts known to be nut free. |
Sponge puddings, crumbles and fruit pies. |
Snacks, soups, sauces, condiments and spreads |
Plain crisps. |
Flavoured crisps and snacks. |
|
Home-made and ready-made soups known to be nut free. |
Dried fruit. |
|
Salt, pepper. |
Salad dressings & mayonnaise. |
|
Fresh herbs and spices. |
Dips, hummus. |
|
Vinegar. |
Stuffing mixes |
|
Soy sauce. |
Oriental and Indian sauces (e.g. for curries and stir-fries). |
|
Marmite™,Bovril™. |
Popcorn cooked in groundnut oil. |
Drinks |
|
Instant chocolate drinks and milkshakes |
Fats and Oils |
Olive/rapeseed/corn/soya/sunflower/palm and vegetable oils. |
Fried foods and Indian or oriental dishes cooked in groundnut, peanut or other nut oils. |
|
Butter, ghee, lard, and margarines made from the from the above oils. |
Salad dressings using unrefined nut oils (e.g. walnut, almond, groundnut oil). |
Non-food sources of nuts
Bird food, pet food and other animal feed may contain nuts. So, remember to check the ingredients if you are handling these products.
Some cosmetics, creams, toiletries, pharmaceutical products (e.g. ear drops, lip balm, throat spray) and vitamin supplements may contain nut or seed oils, but these oils are likely to be refined and therefore very unlikely to cause allergic reactions. Some sensitive individuals may need to avoid skin products containing nut oils, if they develop any localised skin reactions such as an itchy rash. Any nut-containing products taken orally should be avoided by those with a nut allergy.
Cosmetics, pharmaceutical products and supplements are required by EU law to have any nut ingredients listed using the Latin name for peanut - Arachis hypogaea.
Advice for managing a peanut allergy
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It is important that everyone, whatever their age, always carries rescue medication including adrenaline, if this has been described.
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If you have been prescribed an adrenaline autoinjector, you need to feel confident about how and when to use it.
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Tell your friends, work colleagues and employers that you have a peanut allergy, and what to do if they have an allergic reaction.
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Alcohol can affect judgement and a combination of alcohol and heavy exercise can increase the severity of a reaction.
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Be careful when kissing or drinking from the cup or glass of someone who has eaten nuts, as nut protein can be present in saliva for several hours and could cause a reaction.
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Keep asthma well controlled – see GP for help if required.
Tips for eating out
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Thai, Indonesian, Chinese, Indian, Middle Eastern and African meals have a high risk of nut contamination and should be avoided unless you are sure they are nut free as most severe reactions happen with this type of food. If you cannot avoid this then make sure you order your own peanut-free meal, rather than sharing dishes or choosing from a banquet.
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Whichever cuisine you choose, make sure you have all your in date medication with you
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Check out the restaurant’s website – many now contain nutritional and allergy information.
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Ring the restaurant in advance to ask if they can cater for your allergy. Try to call at off-peak times when the staff will have more time to deal with your query.
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Speak to the waiter/waitress or the chef as soon as you are seated to ensure that they are all aware of your peanut allergy. You may find it helpful to use a ‘chef card’ to ask the chef to confirm that the food you have requested is completely nut free. Print off a chef card.
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Get to know the chef in your favourite local restaurant.
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Avoiding the busiest meal times may help to give staff more time to check ingredients properly. If in doubt, go elsewhere.
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Keep to “simple” foods on the menu. Sauces and gravies contain many ingredients that can’t always be remembered by staff. Peanuts may not be mentioned in the description of a dish so, check for hidden sources (e.g. in bread, pastry, salads and desserts). If you do not understand the description of a menu item, it is safer not to order it.
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Self-service areas, buffets and salad bars are also at risk of cross contamination from one dish to another.
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Make sure those you are dining with know about your allergy and know what to do if you have a reaction.
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If eating at a friends house or at a party, remember to tell the host about your nut allergy in advance so they can prepare nut free dishes.
Travel tips
If you are travelling abroad, check in advance how to describe your allergies in the local language. There are several websites that provide useful phrases and eating out translation cards in different languages: Allergy Action, Allergy Free Passport and Allergy UK.
If you are flying, speak to your airline well in advance to check if they can accommodate your dietary needs. On boarding, notify flight attendants of your nut allergy and ask for an ingredient list to check the correct airline meal is given.
Try to choose an airline that doesn’t serve complementary peanut and nut snacks. Some will agree to give alternative nut free snacks on your flight if requested well in advance.
Consider taking snacks for the journey in case your flight is delayed or the requested meal is not available. Try to obtain a letter from your Doctor or Dietitian explaining why you need to take special food items on board. Any items not needed for the flight should be packed in your suitcase. Do not pack fruit, vegetables or meat as you will not be allowed to take these through customs at your destination.
Also check if the airline has any restrictions on the amount of liquid you can take on board. Some will want a Doctor’s letter confirming an allergy before allowing you to take more than 100 ml of liquid (e.g. antihistamine) or an adrenaline auto-injector.
Keep all emergency medication (e.g. antihistamines, adrenaline auto-injector) and action plan close to hand and check they are in date. If flying, do not store auto- injectors in overhead lockers.
Make sure any people you are travelling with know about your allergies and what to do if a reaction occurs.
If you are staying in a hotel, try to get a room with a kitchen in case there are no safe places to eat out.
Wherever you are staying, make sure you have the telephone number of the local hospital or emergency services and keep your medical insurance number handy in case you need it.
Ensure you wear an allergy ID bracelet or card. These and travel containers to protect emergency medicines are available from a variety of websites:. MedicAlert, Medical Bracelets UK, FRIO UK and Anaphylaxis UK.
Useful Contacts
Anaphylaxis UK
A charity organisation providing information & support for people with severe allergies including information on the availability and use of adrenaline auto-injectors. Tel: 01252 542 029.
Allergy UK
A charity organisation providing support for people with allergies. Tel: 01322 619 898.
The British Dietetic Association
Provides fact sheets on food allergy and intolerance, autistic spectrum & allergy testing. Tel: 0121 200 8080.
British Society for Allergy and Clinical Immunology
Allergy information for patients.
NHS food allergy and intolerance advice.
NHS Anaphylaxis advice.
Useful websites
Free From Food Awards. Useful resources about allergy and intolerance.
Nut Free Products
The following companies have dedicated nut free production lines and factories. No product can be guaranteed to be 100% nut free but these companies aim to control all possible sources of nut contamination and therefore may have safer products. These products are available on-line and in health food shops or supermarkets:
Nut Free Food Lists
Many supermarkets and food companies will provide information on their own-brand nut free products. Your Dietitian can provide a separate list of contact numbers and websites if required.
Top tips for living with a nut allergy
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Even small traces of peanut can trigger an allergic reaction. Households where nuts are eaten, extra care is needed in food preparation, cooking and storage in order to minimise the risk of cross contamination.
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Only eat foods you are certain don’t contain peanuts and if you are unsure, leave it out!
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Avoid foods without labels (e.g. from a bakery or delicatessen) and high-risk foods such as Indian and oriental curries and stir-fries, and Italian dishes with pesto sauce that may contain peanut.
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Read food ingredient labels to check for peanuts every time you buy, as product ingredients or manufacturing processes may change.
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All food products with “may contain” warnings are best avoided. However, if you choose to take a calculated risk, only eat foods with these warnings if you have your emergency medication to hand and are within easy reach of a hospital. Avoid: if unwell or asthma poorly controlled; if previously reacted to trace amounts of nut; or after strenuous exercise or drinking alcohol.
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If you do not know whether you can eat tree nuts safely, avoid them until you can discuss this with your Doctor.
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Make sure your emergency plan and medication is always up-to-date and carried at all times.
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Ensure that friends, relatives and work colleagues, are given a copy of your emergency treatment plan and know what to do if an allergic reaction should occur.
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Ensure you and relevant family members feel confident giving emergency medication if required.