Allergeenide nimed erineval moel /Hidden in foods

Deaths in children, adolescents, and adults who ingested foods to which they were highly allergic have been reported.1,2 These deaths are often caused by a "hidden" ingredient in the food to which the individual is allergic.1,3 Yunginger1 suggests that in the United States, more children and adolescents die annually as a result of food-induced anaphylaxis than as a result of insect stings. The majority of these deaths are due to severe allergy to peanut and nuts, and asthma appears to be an important risk factor for this form of allergy.2


Sensitivity can occur by ingestion of minute quantities of food allergens4,5 and even by inhalation of food allergens carried in air or in cooking fumes.6-12 The association between a reaction and a food may not initially he obvious because many patients experience a reaction only several hours later.13,14 Unlike the very acute and often dramatic reaction to peanut, the form of reaction to egg, milk, wheat, and soy may he through "soft signs" (e.g., gastroenteropathies, asthma, and atopic dermatitis).12 Other diagnostic difficulties occur in individuals experiencing anaphylactoid reactions and in patients with food-dependent exercise-induced anaphylaxis. 15


Reasons for allergens being Hidden in foods

Probably the most common reason for sensitive individuals to ingest a hidden allergen is contamination of a safe food. This occurs when the same serving utensils are used for different foods. Salad bars and ice cream parlors offer good examples of this practice. It also occurs when deli meat slicers are used for slicing both cheese and meat and when manufacturers use previously manufactured products for manufacture of a secondary product. Mayonnaise used in the manufacture of a new product may not prompt the listing of mayonnaise or egg. particularly if this ingredient is less than 2% of all the ingredients in the new product. Another form of contamination occurs when a manufacturing plant uses the same equipment to make different products, such as ice cream and milk-free sorbet, without adequate cleaning of the equipment16 or when the same oil is used for cooking French fries and fish in a take-away outlet.12


There are many other ways for allergens to he hidden in food. Misleading labels may disguise hidden allergens. This can he illustrated by nondairy creamers or coffee whiteners, which contain skim milk17 or by meat products that contain soy. Some margarine, claiming to consist of 100% corn oil, may in fact contain skim milk powder. A drink advertised for "people who cannot drink milk" is actually milk with lactase enzyme for individuals with a lactose intolerance, but it clearly still contains milk protein.


Hidden allergens can also occur in processed food when an ingredient is added for a specific application; for example, when egg is used in food products and is listed on the ingredient panel as a binder, protein, or emulsifier. This may also occur when soy is used for its "texturizing" or emulsifying properties. Natural flavors such as pineapple, milk casein, or hydrolyzed soy protein may be used and listed as flavoring or natural flavoring, as in microwave popcorn.


Ingredient switching is another source of concern and may happen when manufacturers change ingredients without making this clear on the label. This can transpire when a shortage of vegetable oil results in substitution with a tropical oil, or as noted previously, when a margarine manufacturer advertises 100% corn oil but adds skim milk without altering the label.


Mistakes take place when consumers assume that a brand of food that uses similar labels for a range of products has similar formulations. Loopholes in labeling regulations allow allergens to be hidden in a food product when a manufacturer is excused from listing an ingredient that is present at less than a specific percentage of the total product.


Another major problem is that a food may be listed on the product label by an uncommon term. This practice is addressed in this article.


Food manufacturing practices vary throughout the world, and because the importation of food is common practice, this review aims to assist the individual with allergies and the traveller by including in the tables as many sources of hidden food allergens as possible.

  Problems relating to some specific foods


Egg is one of the most allergenic of all foods, and minute amounts of egg can result in symptoms within minutes, including life-threatening anaphylaxis. This is also seen after contact with egg through non-oral routes.6,18-20 Reactions may occur the first time a child is given egg.21 Although ovalbumin, ovomucoid, and ovotrans-ferrin have been identified as the major allergens in egg white,21,10 other unnamed allergens of lesser importance have been identified.22 These allergens are also present in egg yolk but in lesser quantities.21


This is important because components of egg may be individually used for specific actions in food preparation. For example, hen's egg lysozyme is used as a preservative in food; and in some countries, notably Japan and Switzerland, lysozyme is used in medications.23,24 Individuals sensitive to hen's egg have been shown to be allergic to lysozyme produced from hen's egg.18,23-26


A variety of descriptions may indicate the presence of egg protein in a product (Table 1). The function that egg performs in a product may be named on the ingredient panel (e.g., binder, emulsifier, or coagulant). Because legislation may permit a manufacturer not to list an ingredient constituting less than a specific percentage of the total product, noodles containing egg may not have egg listed on the ingredient panel. A similar situation may occur when egg white is used to give pretzels, bagels, and other baked goods their shiny appearance. In most products, lecithin is derived from soy, but sometimes it may be egg-derived. Provitamin A (extracted from egg) may be used and described as a colorant, but its antigenic properties are unknown.


In addition to food products (Table 2) that may be dangerous to egg-sensitive individuals, egg proteins are also found in cosmetics, shampoos, and pharmaceuticals, such as the laxative Agarol. A patient allergic to egg should avoid buying fried foods from vendors who use the same frying surface for preparing multiple types of food. Recent evidence suggests that egg-sensitive children can receive measles immunization safely.27


Although rare, avian proteins can induce egg allergy in susceptible individuals.28-31 It has been suggested that duck egg be substituted for hen's egg in egg-sensitive individuals. These individuals are able to tolerate cooked chicken.32


Labels that may indicate the presence of egg protein

Egg white
Egg yolk or yellow
Powdered egg
Whole egg

References 32,37,80,90


Foods that may contain egg protein

Baked goods (most except some breads)
Baking mixes
Bearnaise sauce
Bouillon (in restaurants to clear it)
Breakfast cereals
Cake flours
Candy (see Sweets)
Creamy fillings
Egg noodles
French toast
Hollandaise sauce
Ice cream
Lemon curd
Malted cocoa drinks (e.g., Ovaltine, Ovamalt)
Noodles (egg)
Processed meat products (e.g., bologna, meat loaf, meatballs, sausages)
Salad dressing (creamy)
Sweets (e.g., fondant creams, truffles, marshmallows, etc.)
Tartar sauce
Turkish Delight
Wines (if cleared with egg white)

References 32,91



Patients with very sensitive milk allergy can react to a very small quantity of milk protein, including minor contamination13 and even inhalation of milk powder.7

Milk may be found in a large variety of processed foods (some obvious and others not), including confections, margarine, cheese, and pies (Table III). Cheese and cream contain milk protein and should be avoided. Milk contamination of a product is possible if the same manufacturing equipment is used for various products. There is also a carryover effect when one product is used in the manufacture of another.16 In addition, patients should be careful when ordering sliced products from outlets that use the same slicers for cutting a variety of foods (e.g., cheese and cold meat). Lactose, which may contain residual milk protein,may be found in foods and as a filler in the manufacture of medicines such as Benadryl capsules (United States).


Hypoallergenic milk formulas have been used as a milk replacement for children with milk hypersensitivity. However, hypoallergenic milk formulas are not non-allergenic, and many children react to these, depending on the particular formula.33-36

Common descriptions on ingredient panels are "milk," "pasteurized milk," "full cream milk powder," "dried milk," and "skim milk powder" (Table IV).

Extracted milk proteins added to foods retain their antigenicity and may be described as "casein," "caseinate," "whey," or "whey powder."


In our community, many individuals consider skim milk and skim milk powder not to be milk and substitute these for milk. In some instances milk is used in emulsions and can be described as "caseinate," "emulsifier," or "protein."


Soy products are often purchased by those specifically avoiding cow's milk, with the assumption that a soy-based product is free of cow's milk protein. This is not true. "Vegetarian" cheese may contain cow's milk protein. This term simply means that the rennet used in its manufacture is of vegetable origin.37


Foods that may contain milk protein

Batter-fried foods
Breakfast cereals
Cream sauces
Cream soups
Fish in batter
Gravies and gravy mixes
Ice cream (and "non-milk" fat)
Imitation sour cream
Instant mashed potatoes
Other baked goods
Packaged soups
Soy cheese
Soup mixes
Canned soups
Vegetarian cheese

References 17,32,90,91


Labels that may indicate the presence of milk protein

Artificial butter flavor
Butter fat
Buttermilk solids
Caramel color
Caramel flavoring
Cream Curds
"De-lactosed" whey
Demineralized whey
Dried milk
Dry milk solids
Fully cream milk powder
High protein flavor
Lactalbumin phosphate
Milk derivate
Milk protein
Milk solids
Natural flavoring
Pasteurized milk
Rennet casein
Skim milk powder
Sour cream (or solids)
Sour milk solids
Whey powder
Whey protein concentrate

References 32,80,90



Because of the almost unlimited uses of soy, it is a particularly insidious hidden allergen. As with many other allergens, reactions may occur to very small quantities of soy protein, and anaphylaxis to soybean protein has been reported.2,38,39


Soybean lectin is also an important allergen and has been associated with allergic reactions.40


Soybeans may be ingested as whole beans, as flour, or as oil. In addition, soy can be used in the manufacture of food in a great variety of ways, including as a "texturizer," emulsifier, and protein filler. Soy may thus be listed on the ingredient panel according to its use (e.g., "hydrolyzed protein" or "lecithin"39) (Table V).


Soybean flour is often added to cereal flour and is used extensively in the baking industry. The majority of breads contain some soy flour. Pastries, cakes, biscuits, and baby foods may contain soy flour. It is also used in the manufacture of sausages, processed meats, hamburgers, and other meat products" (Table VI). Fermented soybean may be used in the preparation of soy sauce or Worcestershire sauce. Fermented soy is in wide use as a food in the Far East.


Soy is so widely distributed in processed foods that avoidance of soy in the diet is very difficult. Soy may find its way into a food product when added as a "compound" ingredient. For example, if margarine is added to a food product it will be listed as such, but soy present in the margarine itself will not be listed on the ingredients panel.


Soy protein isolate or concentrate may be used to emulsify fat in food products and may thus be used in the manufacture of ice cream, mayonnaise, and a variety of other liquid fat- or oil-containing foods. The concentrate or isolate may also be used in soy milk and as a protein concentrate added to health foods and high-protein biscuits. Other foods that may contain soy include pureed and cereal baby foods, margarine, and white and brown bread39 (Table VI).


Other uses for soy include the manufacture of tofu (soybean curd), which may in turn be used for the manufacture of soy-based ice cream. Soy may be converted into products having a meat-like texture.41 This "textured vegetable protein" is used in simulated meat products or may be added to meat as an extender. These products are often used as meat substitutes in vegetarian products and in catering establishments, including hospital and army food services, and feeding programs.


The seeds of soybeans are widely used as a source of oil. The oil has many uses (e.g., in salad dressings, margarine, baby foods, industrial components, linoleum, paint, plastics, soap, and glue for plywood) (Table VII). Although soybean oil was initially thought to be safe for soy-sensitive individuals,42 it is now evident that soy protein may occur in soybean oil.43 Thus the allergenicity of soybean oil would depend on its purity, which in turn depends on the extraction process. Recent evidence has demonstrated that although oxidized soybean oil may not show allergenicity, proteins in soybeans are capable of interacting with oxidized lipid to form products that are allergenic to soybean-sensitive patients.44 Indeed, Hiyama et al.45 report a case of urticaria associated with paren-teral nutrition with an intravenous 10% lipid emulsion containing a soybean oil base. Such reactions, however, appear to be uncommon, and there are very few reports of this nature in the literature.


Soy products are often purchased by those specifically avoiding cow's milk, often with the assumption that a soy-based product is free of cow's milk protein. This may not always he true, and caution is required. Again, labels should be read carefully, and they should, of course, contain the correct declaration.


Thickeners, stabilizers, emulsifiers, and bulking agents may be manufactured from a variety of other members of the legume family in addition to soybeans. On the basis of in vitro studies, Barnett et al.46 suggested that there may be cross-reactions between soy and other members of the legume family (Table VIII). Further evidence for broad cross-reactivity has been provided by RAST and skin prick tests: however, it is rare to have symptomatic reactivity to more than one member, and clinical hypersensitivity to one legume does not require elimination of the entire legume family.47,48 Carob, derived from the carob bean. is used commonly as a chocolate substitute, and one should possibly guard against cross-reactivity to this legume. Peanut sensitivity is discussed below.



Labels that may indicate the presence of soy protein

Gum arabic
Bulking agent
Guar gum
Hydrolyzed vegetable protein (HVP)
MSG (Monosodium glutamate) !
Protein extender
Soy Flour
Soy nuts
Soy panthenol
Soy protein
Soy protein isolate or concentrate
Soy sauce
Soybean oil
Textured vegetable protein (TVP)
Vegetable broth
Vegetable gum
Vegetable starch

References 39,90,92
* Mostly produced from soy but may be manufactured from egg.
! Sometimes produced from soy or wheat but now mostly by synthetic means.39


Foods that may contain soy protein

Baby foods
Bakery goods*
Black pudding
Bread (esp. high-protein bread)*
Breakfast cereals (some)
Burger patties
Butter substitutes
Canned meat or fish in sauces*
Canned or packaged soups*
Canned tuna
Cheese (artificial) made from soybeans*
Chinese food
Chocolates (cream centers)
Cooking oils
Gravy (sauce) powders
Hamburger patties
Hot dogs
Hydrolyzed vegetable protein (may be wheat)
Ice cream
Infant formula (including cow's milk formula)
Liquid meal replacers
Meat products (e.g., sausages, pastes. Vienna sausages [wieners])
Pies (meat or other)*
Powdered meal replacers
Salad dressings
Sauces (e.g.. Worcestershire, sweet and sour, HP.,Teriyaki)
Seasoned salt
Snack bars
Soy pasta products
Soy sauce
Soy sprouts (Chinese restaurants)
Stews (commercial)
Stock cubes (bouillon cubes)
TV dinners

References 39,90,91

* May be present because of soya in the flour used.


Other sources of contact with soy

Body lotions and creams
Dog food
Enamel paints
Fabric finishes
Flooring materials
Printing inks

Reference 93


Members of legume family

Aduki beans
Broad bean
Black turtle bean
Black-eyed bean
Chick pea
Fava bean
Garbanzo bean
Great Northern bean
Green bean
Kidney bean
Lima bean
Mung bean
Navy bean
Pinto bean
Snap bean
String bean
Wax bean
Other members
Alfalfa (sprouts)
Acacia (gum)
Carob (chocolate substitute)
Cassia or senna (in laxatives, curry, cinnamon)
Fenugreek (used in curries, cinnamon,
  primary flavoring in imitation maple syrup)
Masur bean
Green pea
Purple-hull pea
Senna or cassia (in laxatives and Epsom salts)
Tragacanth (gum)

References 46,47,90



Wheat is the most allergenic of all cereals. lgE antibodies have been demonstrated lo many components of wheat kernels, including albumin, globulin, gliadin, wheat germ agglutinin, a concanava-lin A-purified glycoprotein, and a trypsin inhibitor.49-52 Wheat is most rich in gluten, with the other grains containing a lesser mixture of gluten and gliadin. In addition to being present in all wheat-based food products, wheat gluten is frequently added to baked products made from other grains, including those made from soy flour.


Wheat-sensitive individuals should avoid a product that includes other flours, because it is likely that at least some wheat flour or a derivative will also be present.53 Even "gluten-free" bread may contain small amounts of part of the wheat family.49,56 Spelt may better be described as nonhybridized wheat.56 No data have indicated differences in the allergenic profiles of the various wheat varieties, and they should all be viewed as potential allergens.


Hydrolyzed wheat proteins can be used in processed foods for flavoring purposes (e.g., in meat flavorings) or as a binder in vegetarian burgers. In the United States legislation dictates that this form of wheat must be labeled as wheat-derived, but this is not always the case in other countries. Wheat can appear under various names on ingredient panels (Table IX) and can be found in many food products (Table X). Gluten finds its way into a few pharmaceutical products (e.g., Dimetapp LA, Nu-lacin, and Fybranta).57


Buckwheat is not a member of the grass family and is thus not a true cereal.58 The grain may be used for human food in various forms from pancake flour to buckwheat noodles and baby foods58


For the wheat-hypersensitive individual, products made from oats, rice, rye, barley, or corn or speciality foods made for gluten-sensitive individuals generally may be used instead of wheat. However, cross-reactions, although unusual, may occur between wheat, barley, rye, maize, rice, and sorghum,8,59,60 as well as between the pollens of cereals and cereal flours.61


Labels that may indicate the presence of wheat protein

All-purpose flour
Bleached flour
Bulgur (cracked wheat)
Durum wheat
Enriched flour
Gelatinized starch* (or pre-gelatinized)
Graham flour
Hard durum flour
High gluten flour
High protein flour !
Hydrolyzed vegetable protein !
Miller's bran
Modified food starch*
Modified starch*
MSG (monosodium glutamate)**
Unbleached flour
Vegetable gum*
Vegetable starch*
Vital gluten
Wheat bran
Wheat flour
Wheat germ
Wheat gluten
Wheat starch
White flour
Whole wheat
Whole wheat flour

References 48,49,54,55,57,80,90

* May indicate the presence of soy protein50
    or may he manufactured from cassava (tapioca), maize, or rice.
! Sometimes produced from soy or wheat but now mostly by synthetic means.
** May be soy.



Foods that may contain wheat

Alcoholic beverages
(made from grain alcohol) Ale
Baked goods
Biscuits Breads (including rye bread)
Crackers, etc.
Baking mixes
Barley bread and drinks
Battered foods
Bouillon cubes
Breaded meats
Breaded vegetables
Breakfast cereals
Candy or chocolate candy
Canned processed meat
Cereal grains
Hot dogs
Ice cream
Ice cream cones
Luncheon meats
Malted milks (e.g., Horlicks)
Milk shakes
Noodle products
Pasta (noodles, spaghetti. macaroni)
Pepper (compound or powdered flour filler)
Processed meats
Snack foods
Soup mixes
Soy sauce

References 57,90,91



Peanuts are one of the most allergenic foods,62,63 and peanut allergy is one of the most common food allergies.64 Peanuts are probably the most common cause of death by food anaphylaxis in the United States, and about one third of peanut-sensitive patients have severe reactions to peanuts.65,66 Peanuts are added to a large variety of processed foods (Table XI). These include ice cream (as a flavoring), marinades, snack foods, and biscuits. Peanuts can be used as a flavoring or a seasoning agent67 and may be labeled as such (Table XII). Nuts may be used in the manufacture of vegetable burger patties.68 A fatal reaction to peanut antigen in almond icing has been recorded.69 Peanut butter may also be used to "glue down" the ends of egg rolls to keep them from coming apart.70 Some individuals do not know that peanut butter is commonly used in Oriental cooking.


Peanuts can be "deflavored," "reflavored," and pressed into other shapes such as almonds and walnuts.9,65 These products retain the allergenicity of the peanut. Some patients with peanut allergy also react to sweet lupine seed flour, which may be used, for example, to fortify a spaghetti-like pasta.71


Although uncommon, a peanut protein hydrolyzate may also be used in soft drinks as a foaming agent or in confections as a whipping agent.67


Peanut oil has been considered to be devoid of allergenicity,72,73 and this was initially confirmed by double-blind crossover studies.74 However, peanut oil allergenicity is clearly process-related, because cold-pressed peanut oils may contain peanut allergen.75 Moneret-Vautrin et al.76,77 confirmed the allergenicity of peanut oil in milk formulas, and 11 of 45 brands of milk formulas in France contained variable amounts of peanut oil.77 Residual peanut proteins arc believed to become more allergenic with heating.77


The oil is frequently used in the preparation of so-called "health foods." The oil can be used for many nonfood products, which may, on contact, affect sensitive individuals. Like peanut oil, other vegetable oils such as soy, maize, sesame, and sunflower oils contain very low quantities of protein.78,79


Individuals who are allergic to peanuts are said to not be allergic to nuts such as almonds, pecans, or walnuts; and these nuts can be substituted for peanuts.9 This is contradicted by a recent study, which showed that 50% of individuals allergic to peanuts reported allergic reactions to other nuts as well.70 These findings were not validated by further clinical investigation.


Foods that may contain peanut or peanut oil.

Baked goods
Baking mixes
Battered foods
Breakfast cereals
Cereal-based products
Chinese dishes
Egg rolls
Ice cream
Milk formula
Peanut butter
Satay sauce and dishes
Thai dishes
Vegetable fat
Vegetable oil

References 66,70,72


Labels that may indicate the presence of peanut protein

Peanut butter
Emulsifier (uncommon)
Oriental sauce

Reference 67



Fish are one of the most common causes of food allergy, particularly in adults and in Scandinavian countries.9 Fish may find their way into processed foods in raw, powder, or oil form. In the majority of instances, this substance is clearly labelled as "fish" or with another obvious descriptor. However, fish allergens may be found unlisted if added as part of an oil. Fish products are not usually hidden ingredients but may be hidden in Caesar salad dressing or in Worcestershire sauce if it contains anchovies.9


Some seafood flavors (e.g., shrimp) arc added to food in the form of a powder manufactured from the seafood's shell. Shrimp antigen II is heat stable."' A variety of antigens are shared by several crustaceans including shrimp, prawns, crabs, lobsters, and crayfish (crawfish).


At present, some manufacturers are researching the possibility of adding fish meal (flour) to bread as a source of omega-3-fatty acids (personal communication, M. M. Melnyczuk). Skin prick tests and RASTs indicate extensive cross-reactivity among fish species, but recent research suggests that patients may be able to consume some species of fish despite positive test responses to one or two.81 However, it is generally recommended that patients allergic to fish avoid all fish species.


A major difficulty in identifying a food allergen in some patients is that they may he unaware of the connection between a specific food and allergic symptoms, because the symptoms may appear much later.13,14 Although clinical history and routine laboratory studies have great predictive value in most individuals with food allergy, they may have little value in predicting which foods are responsible in many others, particularly in adults.64,82,83 Moreover, in some individuals with a history of a reaction to food, there may be poor correlation between history and results of skin tests, in vitro blood tests, and double-blind, placebo-controlled food challenges.64,84-86 The double-blind, placebo-controlled food challenge remains the gold standard in the diagnosis of food hyper- sensitivity, and in the event of negative skin prick test and RAST results, may be the only method with which to confirm a food hypersensitivity.87,88


One clear message from the literature is that most fatal and near-fatal reactions happen when eating away from home.2,3,11,69,89 Individuals with severe food hypersensitivity should probably avoid processed foods. If it is necessary to purchase these foods, they should be made by a reliable manufacturer. Parents and children can learn to scrutinize food labels carefully. Unfortunately, the multiplicity of possible names for any one ingredient may let a hidden allergen slip by. If possible, hypoaller-genic formulas should be tested in each case before being prescribed for children sensitive to cow's rnilk.35,36 The very sensitive individual should wear a Medic Alert bracelet and carry an epinephrine (adrenaline) self-injector at all times.1 Less sensitive individuals may need to carry antihistamincs with them.


Fortunately, many individuals lose their reactivity to foods over time, albeit not completely in some. Bock89 recommends careful and periodic challenges in these patients to save families from prolonged anxiety about accidental ingestion. Unfortunately, sensitivity to peanut is seldom outgrown.66


Acknowledgement should be made to the food industry for the strides made in improved labeling of food products, in many countries, the food industry has played a leading role in constructing food intolerance databases, which can assist sensitive individuals in avoiding foods containing a particular ingredient. In the long term, manufacturers must he persuaded to bring common ingredient names into use, and legislation should be passed to make food labels more accurate. A possible solution would he to list the derivative in brackets after the ingredient, for example, ovomucoid [egg].


I thank Dr. Sarah Ruden (Department of Classics, University of Cape Town). Prof. Eugene Weinberg (Allergy Clinic, Red Cross Children's Hospital, Ronde-bosch). Prof. Paul Potter (Allergology Unit. University of Cape Town Medical School. Observatory). Tanya and Mikhailo Melnyczuk of Roberts & Melnyczuk Food Research & Development Consultants, and Ronn Timm (South African Association of Food Scientists and Technologists and Royal Beechnut Pty. Ltd.) for their advice and expertise.



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Journal of Allergy and Clinical Immunology 1996;98(2):241-250
with permission from Mosby-Year Book, Inc