food is an integral part of life ; however , for some , it can cause allergies and may even lead to fatality .
it is necessary to appreciate the large impact that culture and ethnicity have on food choices , eating styles , and patterns , especially in defining and accepting the diagnosis of food allergies . in 1990 , food allergies were estimated to affect 1.5% of adults in the united states and 6% of children younger than 3 years of age [ 1 , 2 ] . although food allergy ( fa ) is an important health problem in western countries , its prevalence varies among geographic regions .
there is limited data on the prevalence of food allergy in the middle east ; the data from turkey and mediterranean region are even scarce . in a study done in the uae ( al - ain city ) ,
eggs , fruits , and fish were the main allergens reported . without comprehensive data on the prevalence of food allergy
, it will be impossible to develop appropriate local diagnostic tools and avoid the incidence of anaphylaxis to food .
a clear understanding of the extent of food allergies will help public health services to be reactive rather than proactive .
the main objective of our study is to assess the prevalence of self - reported food allergy in lebanon .
secondary objectives include describing the principal food allergens , reporting the symptoms of food allergy in our group , the diagnostic tools , and the presence of concomitant allergic diseases .
the survey was conducted by a questionnaire given during telephone calls through random selection of landline phone numbers from the white pages all over lebanon .
the number of phone calls performed varied between 1500 and 2000 until reaching 500 answers stating yes or no ( accepting to participate in the survey ) .
data collectors  hold a b.s . degree in biology , biochemistry , public health , or pharmacy with at least 6 years of experience in the pharmaceutical domain .
they are well trained to run a professional conversation with patients and handle such surveys and any objection that might arise while answering the questionnaire . the sample for phone calls was randomly selected from white pages based on regional split , coded , and distributed to  data collectors  in anqors consulting .
codes assigned to each questionnaire were used during data verification , feeding , and analysis .
if there is an answer , check if the person answering is eligible to participate ( adult , the household , etc . ) .
introduce the survey to check acceptance for participation as follows :  good morning / evening ; we are calling from a professional company who holds surveys in the medical domain .
we are running a survey all over lebanon to assess the prevalence of food allergy .
if the answer is  yes ,  proceed with the questionnaire.if the answer is  no , 
if there is an answer , check if the person answering is eligible to participate ( adult , the household , etc . ) .  
good morning / evening ; we are calling from a professional company who holds surveys in the medical domain .
we are running a survey all over lebanon to assess the prevalence of food allergy .
no names or addresses were requested while answering the questionnaire .   step  4 . if the answer is  yes , 
later on , the phone calls were split per region depending on the number of landlines per region ( relative to demographic distribution ) along with the response rate per region received during the pilot phase run at the beginning of june 2014 .
the medical research was run through phone calls survey targeting houses and the results presented herein are qualitative and quantitative ( percentage estimates ) .
the only personal data about the responder and/or allergic person are his age and sex . based on previously established prevalence rate of 3% through literature review and an estimated 95% confidence interval of 1.54.5% , a sample size of 506 subjects was needed for the study . a pilot study with a sample of 100 subjects was taken from digitalized white pages to assess the response rate in order to decide on the final sample of phone numbers needed . based on a response rate of 27.6% ,
the preliminary target was 1500 call attempts , which were increased to 1832 to obtain 506 responses . adults or grownups were interviewed over the phone and asked if they or any of their kids suffered from food allergies .
the fieldwork started at the beginning of july 2014 and continued over a period of 7 weeks .
people were first asked about whether they / nonadult housemates suffer from any type of food allergy or not .
food allergy sufferers ' calls elapsed for around 10 minutes . a questionnaire addressing the main objectives of the study
self - reported food allergy is estimated to be 4.1% in infants and children and 3.2% in adults .
the majority of self - reported food allergy prevalence was reported at childhood and adulthood with only 8% below 2 years of age ( figure 1 ) .
fruits ranked first as food allergens with 35% prevalence in the open - ended question , mainly strawberry ( 16% ) and peach ( 14% ) , followed by eggs ( 19% ) and nuts ( 16% ) ( figure 2 ) .
cow 's milk and spices came fourth when answering specifically about allergen classification in the questionnaire , with 14% prevalence ( figure 3 ) .
73% of participants mentioned that they are allergic to a single food allergen and 22% mentioned that they are allergic to two food allergens , while only 5% reported allergy to three food allergens .
skin reactions , including hives , itching , and redness , are the most common symptoms among food allergy sufferers , reported in 86% of the cases .
30% of food allergy sufferers reported facial swelling and 14% suffer from shortness of breath , throat swelling , angioedema , and cough , while 11% mentioned face swelling and angioedema with nausea / vomiting .
allergists , dermatologists , gastroenterologists , or gps are consulted for medical advice ( figure 4 ) .
75% of patients suffering from nausea and vomiting are more likely to seek medical advice to diagnose food allergy .
only 5560% of patients suffering from skin reactions , face swelling , and trouble in breathing seek medical advice for food allergy .
patients suffering from throat tightness and itchy throat , lips , and mouth are the least to consult a physician ( figure 5 ) .
the most common diagnostic tool requested by medical professionals was blood test ( specific ige ) ( 55% ) followed by other options such as food elimination based on clinical history ( 25% ) and allergy skin prick testing ( 20% ) .
73% of patients suffering from food allergy ask about food ingredients in case of non - self - prepared food .
75% of patients who seek medical advice check for food ingredients in non - self - prepared food .
51% of participants with food allergy have concomitant allergic diseases , such as allergic rhinitis in 30% of the cases , drug allergies ( mainly antibiotics , aspirin , and nonsteroidal anti - inflammatories ) in 16% of cases , and asthma in 5% of the cases .
in the past 2 decades , food allergy has emerged as an important public health problem , affecting people of all ages in societies with a western lifestyle , such as the united states , canada , united kingdom , australia , and western europe [ 6 , 7 ] .
food allergy is the most common cause of anaphylaxis in the outpatient setting for all ages , and it can lead to fatalities .
prevalence and moreover incidence of food allergy are often difficult to assess because their evaluation is influenced by multiple factors such as allergy definition , study population , methodologies , geographic variation , age , and dietary exposure .
a recent meta - analysis showed that self - reported prevalence of food allergy varied from 1.2% to 17% for milk , from 0.2% to 7% for egg , from 0% to 2% for peanuts and fish , from 0% to 10% for shellfish , and from 3% to 35% for any food .
marked heterogeneity in the prevalence of food allergy was noticed and could be a result of differences in study design or methodology or differences between populations .
the authors concluded that self - reported food allergy could not give a good estimate of food allergy . in recent population - based studies in the united states , 1.3% of adults
self - reported peanut allergy , tree nut allergy , or both ; 2.8% of adults self - reported seafood allergy ; and the adult population allergic to food was estimated to be 4% .
limited data suggest that the prevalence of food allergy has increased in industrialized countries worldwide ; for example , estimates of peanut and tree nut allergy tripled in american children between 1997 and 2008 , but the reason for this increase remains unknown .
examples include sesame in the middle east , buckwheat in japan , and mustard and lupine in france [ 11 , 12 ] .
however , to our knowledge , few population - based studies in the middle east have determined the prevalence of food allergy . in the middle east ,
a recent study done in the united arab emirates showed that the most common food allergens were seafood and nuts .
the prevalence of physician - diagnosed fa in children in the uae was 8% ( 95% ci : 5.410.8% ) .
eggs , fruits , and fish were the main allergens reported . in a previous study done by our group , we identified 386 out of 1842 ( 20.95% ) patients with positive specific ige to food allergens .
the major sensitizations were to cow 's milk in infants and young children and to hazelnut and wheat flour in adults .
although specific ige was more commonly detected to peanut in infants , children , and adults than to sesame , peanut - induced allergic reactions were mild , in contrast to sesame where anaphylaxis was the only clinical manifestation .
studies that measure sensitization to food allergens can overestimate the prevalence of true allergic reactions to foods , because not all sensitized patients will develop symptoms upon ingestion .
in contrast , the rates of food allergy are significantly lower if allergy is defined by verified clinical reactivity upon ingestion . in one study of food allergy in saudi patients ,
specific ige antibodies for various food allergens were detected in 38 ( 17.5% ) out of 217 patients .
most positive reactions were detected in urticaria patients ( 9.7% ) followed by asthmatics ( 5.5% ) and allergic rhinitis patients ( 2.3% ) .
reactions to peanut ( 22.6% ) , egg white ( 14.5 ) , and cow 's milk ( 12.9% ) were very prominent .
pertinent questions along with the timing and type of manifestations are essential to differentiate the two conditions .
our questionnaire addressed this issue by excluding all cases that reported symptoms more than 2 hours after food ingestion and patients presenting with irritable bowel symptoms such as bloating .
parents and grandparents are not easily convinced to avoid certain food in their child 's diet .
education is imperatively needed in order to avoid delay in diagnosis and proper management with an action plan .
unfortunately , epinephrine autoinjectors are not available in the country , and when prescribed they are bought from other countries .
plant food allergy is more common in patients with pollinosis than in the general population .
this may explain the highest incidence of allergy to fruits in our population which is similar to the population described in the mediterranean area .
this is a pilot study of self - reported food allergy prevalence in lebanon based on a telephone survey .
self - reported prevalence is estimated to be 4.1% in infants and children and 3.2% in adults .
advocacy for proper diagnosis , food elimination , and acquisition of epinephrine autoinjectors will hopefully result from our national study .
 
 background . 
 food allergy ( fa ) is an important health problem in western countries but there is limited data on the prevalence of food allergy in the middle east . 
 the main objective of our study is to assess the prevalence of self - reported food allergy in lebanon 
 . methods . 
 the survey was conducted by telephone calls questionnaire through random selection of landline phone numbers from the white pages all over lebanon . 
 a study questionnaire addressing the main objectives of the study was filled during the telephone call conversation . 
 results . 
 food allergy prevalence is estimated to be 4.1% in infants and children and 3.2% in adults . 
 65% of patients suffering from food allergy are females and 35% are males . 
 skin reactions are the most common symptoms among food allergy sufferers , reported in 86% of the cases . 
 signs of anaphylaxis appeared in 10.8% of cases . fruits were the most common allergens at 35% , followed by eggs ( 19% ) and nuts ( 16% ) . 
 cow 's milk and spices ranked fourth ( 14% ) . 
 only half of food allergy sufferers sought medical advice . 
 allergists , dermatologists , gastroenterologists , or gps ( general practitioners ) were consulted . 
 blood testing for specific ige was the main diagnostic tool used by physicians . 
 conclusion . 
 this is a pilot study of self - reported food allergy prevalence in lebanon based on telephone survey . 
 general prevalence is estimated to be 4.1% in infants and children and 3.2% in adults . 
 our study may improve awareness for proper diagnosis , food elimination , and acquisition of epinephrine autoinjectors in this part of the world . 
1. Introduction
2. Methods
3. Results
4. Discussion
5. Conclusion