Curr Allergy Asthma Rep (2015) 15: 54

DOI 10.1007/s11882-015-0555-8

FOOD ALLERGY (T GREEN, SECTION EDITOR)

The Prevalence of Tree Nut Allergy: A Systematic Review

Vicki McWilliam 1,2,4 & Jennifer Koplin 1,3 & Caroline Lodge 3 & Mimi Tang 1,2,4 &
Shyamali Dharmage 1,3 & Katrina Allen 1,2,4,5

Published online: 2 August 2015

# Springer Science+Business Media New York 2015

Abstract Tree nuts are one of the most common foods causing (8–11.4 %) and were predominantly from Europe. Prevalence
acute allergic reactions and nearly all tree nuts have been asso- of individual tree nut allergies varied significantly by region
ciated with fatal allergic reactions. Despite their clinical impor- with hazelnut the most common tree nut allergy in Europe,
tance, tree nut allergy epidemiology remains understudied and walnut and cashew in the USA and Brazil nut, almond and
the prevalence of tree nut allergy in different regions of the walnut most commonly reported in the UK. Monitoring time
world has not yet been well characterised. We aimed to system- trends of tree nut allergy prevalence (both overall and by indi-
atically review the population prevalence of tree nut allergy in vidual nuts) as well as the prevalence of OAS should be con-
children and adults. We searched three electronic databases sidered given the context of the overall recent rise in IgE-
(OVID MEDLINE, EMBASE and PubMed) from January mediated food allergy prevalence in the developed world.
1996 to December 2014. Eligible studies were categorised by
age, region and method of assessment of tree nut allergy. Of the
36 studies identified most were in children (n=24) and from Keywords Tree nut allergy . Systematic review . Prevalence .
Europe (n = 18), UK (n = 8) or USA (n = 5). Challenge- Epidemiology
confirmed IgE-mediated tree nut allergy prevalence was less
than 2 % (although only seven studies used this gold standard)
while probable tree nut allergy prevalence ranged from 0.05 to Abbreviations
4.9 %. Prevalence estimates that included oral allergy syn- Primary tree IgE-mediated allergic reaction upon exposure
drome (OAS) reactions to tree nut were significantly higher nut allergy to tree nuts that is due to a specific immune
response directed against tree nut allergens
Secondary IgE-mediated allergic reaction upon exposure
This article is part of the Topical Collection on Food Allergy tree nut to tree nuts that is due to cross-reactivity of
allergy specific IgE directed against non-tree nut
* Katrina Allen allergens
[email protected] Tree nut Presence of tree nut allergen-specific IgE
sensitisation measured by skin prick test (SPT) or specific
1
Murdoch Childrens Research Institute, Royal Children’s Hospital, IgE blood testing (sIgE)
Flemington Rd, Parkville 3052, Victoria, Australia Oral allergy A secondary tree nut allergy that occurs pre-
2
Department of Paediatrics, University of Melbourne, syndrome dominantly in pollen-sensitised individuals,
Parkville, Australia (OAS) mediated by cross-reactive IgE responses to
3
Allergy and Lung Health Unit, Centre for Epidemiology and allergens present in pollen and other plants.
Biostatistics, The University of Melbourne, Melbourne, Australia Presents with oral pharyngeal symptoms
4
Department of Allergy and Immunology, The Royal Children’s (itching mouth/tongue)
Hospital, Flemington Road, Parkville, Australia Pollen food Another term for oral allergy syndrome
5
Institute of Inflammation and Repair, University of Manchester, syndrome
Manchester, UK (PFS)
54 Page 2 of 13 Curr Allergy Asthma Rep (2015) 15: 54

Introduction prevalence of perceived reactions to tree nut as ranging be-

tween 0 and 7.3 %; however, most studies included in this
Tree nut is the collective term used to describe nuts that grow review (n=27 of 36) were based in Europe where the preva-
on trees. Contrary to popular belief, peanuts are not tree nuts lence of oral allergy syndrome is high, and few studies used
and are in fact a groundnut and classified as a legume. Tree objective definitions of tree nut allergy such as challenge con-
nuts most likely to result in an IgE-mediated food allergy firmed outcomes [12•]. A more recent systematic review by
reaction are almond, brazil nut, cashew nut, hazelnut, Nwaru et al. was confined to European studies only and did
macadamia, pecan, pistachio and walnut. Although botanical- not distinguish between individual tree nuts [13•]. A more up-
ly unrelated, tree nut and peanut allergies share many clinical to-date global prevalence estimate of tree nut allergy is needed
similarities. Peanut and tree nuts are two of the most common since 20 new studies have been published since 2006, and
foods reported to cause IgE-mediated food allergic reactions. understanding the regional variation in tree nut allergy is im-
IgE-mediated food allergy reactions can occur after ingestion portant given the overall rising burden of food allergy [14, 15]
of very small amounts of peanut and tree nut, typically within in developed countries and the importance of tree nuts as a
minutes of ingestion with symptoms including hives, angio- cause of severe allergic reactions.
edema or vomiting. Reactions can also be life threatening, The aim of this paper is to provide a comprehensive, up to-
with the most severe reactions termed anaphylaxis. Peanut date systematic review of the population prevalence of tree nut
and tree nuts together account for 70–90 % of reported food- allergy in children and adults including details of all individual
induced anaphylaxis fatalities, with tree nuts alone accounting tree nuts in various regions of the world.
for around 18–40 % [1–4]. Allergies to peanut and tree nuts
also commonly co-exist with around 20–30 % of people with
a peanut allergy also allergic to one or more tree nuts [5, 6].
Methods
For individuals with one tree nut allergy, around 30 % will
have at least one additional tree nut allergy [6]. Tree nut and
Search Strategy
peanut allergies are usually lifelong [7]. Peanut allergy has
been well described and widely reported with population
Following closely the methods and procedures of the Pre-
prevalence estimates between 1 and 6 % [8•, 9]. Despite the
ferred Reporting Items for Systematic Reviews and Meta-
similarities to peanut allergy, the population prevalence of tree
analyses (PRISMA) guidelines [16], we systematically
nut allergy has been less well characterised.
searched three electronic databases (OVID MEDLINE,
Determining tree nut allergy prevalence at a population
EMBASE and PubMed) based on a search strategy formulat-
level can be complex. Firstly, the definition of a ‘tree nut’
ed with the assistance of a research librarian. The search strat-
may vary. Some studies include peanut and tree nuts together
egy was created in OVID MEDLINE and modified for
as ‘nuts’, while other studies only include one or two tree nuts.
EMBASE and PubMed. Figure 1 outlines the full OVID
Few studies investigate allergy to all eight common individual
MEDLINE search strategy.
tree nuts. Secondly, allergic reactions to tree nuts can result
from primary IgE-mediated mechanisms or, alternatively, via
secondary cross-reactivity mechanisms to birch pollen, in a Study Selection
form of food allergy known as oral allergy syndrome (OAS)
or pollen food syndrome (PFS). In individuals with birch pol- Tree nuts were defined as walnut, almond, pistachio, cashew,
len sensitisation, birch pollen-specific IgE can cross-react with pecan, hazelnut, macadamia and Brazil nut. Studies reporting
similar proteins found in a range of fresh fruits, vegetables and on all forms of allergic reactions (primary and secondary IgE-
nuts (apple, apricot, carrot, celery, hazelnut, peach, peanut, mediated and non-IgE-mediated reactions) were included and
pear, potato and plum) resulting in oral pharyngeal symptoms there were no age restrictions applied. All tree nut allergy
[10, 11]. Finally, the method of tree nut allergy diagnosis may outcomes were included for both individual and combined
vary from self-reported methods such as surveys and question- tree nut allergies. We included eligible studies that reported
naires (which have been found to overestimate the true prev- tree nut allergy based on self-report, sensitisation (sIgE or
alence of food allergy) [8•, 9], IgE testing methods such as SPT), OFC/DBPCFC or convincing clinical history. The
skin prick testing (SPT) or specific IgE (which are limited to search was limited to English-language articles and, to capture
IgE-mediated food allergy and are indicative of sensitisation more recent publications, limited to the period January 1996
not clinical allergy), to the most objective but time-consuming to December 2014. To ensure unbiased estimates of tree nut
and cumbersome methods of oral food challenge (OFC) and allergy prevalence in the community, we excluded studies in
double-blind placebo-controlled food challenges (DBPCFC). selected patient groups or those performed in hospital or aller-
One previous systematic review by Zuidmeer et al., of gy clinic settings and included only population-based cross-
studies published between 1990 and 2006, reported the sectional and cohort studies. Reviews and case reports were
Curr Allergy Asthma Rep (2015) 15: 54 Page 3 of 13 54

Embase(Jan 1996-Dec 2014) Medline (Jan 1996-Dec 2014)* PubMed (Jan 2013-Dec 2014)

n=230 n=130 n=11

Records aer duplicates removed

n= 333

Records screened (tle/ abstract) Records Excluded

n=333 n=261

Full text-arcles assessed for

Addional records idenfied eligibility
n= 10
n=82

Full text arcles excluded n= 46

Total
Selected populaon = 26, Treenut allergy prevalence not
n=36
reported =7, Review arcle = 6,No Prevalence data = 7

* The primary search was conducted in OVID MEDLINE and modified for EMBASE and PubMed. The
search involved a combinaon of three search groups as either MeSH terms or keywords, each of
which had to be present in order for an arcle to be included: 1) “nut s”, “tree nuts” or an individual
tree nut term; 2) “hypersensivity” or “allergy”; and 3) “prevalence” or “epidemiology”. The search
was limited to English language arcles. The exact search conducted in OVID MEDLINE is shown in the
box below.
1. (hazelnut* or hazel nut* or cashew*or pistachio* or almond* or treenut* or tree nut* or pecan* or brazilnut* or brazil nut*
or walnut*).af. 2. Nuts/ae, im, po, to 3. prevalence 4. Epidemiology 5. food hypersensitivity/ or nut hypersensitivity 6.
allerg*.af. 7. (1 or 2) and (3 or 4) and (5 or 6) 8. nut hypersensitivity/ep 9. food hypersensitivity/ep and (1 or 2) 10. 7 or 8 or
9 11. limit 10 to english language

Fig. 1 Summary of the search method

excluded along with studies of which full-text articles were Analysis

not available.
Identified articles were screened via title and abstract by Using a standardised method, relevant study details were
two independent reviewers. Any discrepancies were resolved summarised including reference details, age, sample size
by consensus and if necessary a third reviewer consulted. Ref- and response rate, prevalence estimates and 95 % confi-
erence lists of identified studies were reviewed for additional dence intervals (CI) for all reported food allergy out-
articles. A full-text review was then undertaken for all articles comes (self-/parent report, specific IgE testing, skin prick
identified. testing, symptoms and food challenges) for overall food
Quality assessment of the studies was performed by two allergy and tree nut allergy. If not reported, prevalence
reviewers based on participation rate, ability of the study de- estimates were calculated as the observed proportion
sign to address tree nut allergy outcomes objectively and in- with 95 % CI calculated on the assumption of a binomial
clusion of individual tree nut information. sampling distribution.
54 Page 4 of 13 Curr Allergy Asthma Rep (2015) 15: 54

We subclassified the prevalence estimates and 95 % CI for tree nut prevalence data, which we have included in this review.
age, region and method of tree nut allergy diagnosis. The majority (n=28) of the studies were population-based cross-
For this review, the approaches used to determine tree nut sectional studies and the remaining eight were cohort studies.
allergy have been grouped as follows: Six studies did not provide participation rate details, ten studies
had a participation rate above 80 %, 13 between 50 and 80 %
1. Confirmed tree nut allergy—defined as food challenge and seven less than 50 %. One study by Greenhawt et al. in
confirmed tree nut allergy (OFC or DBPCFC) or recent American college students had a participation rate of only 3 %
history (<2 years) of IgE-mediated reaction with positive and reported a very high overall self-reported food allergy prev-
allergy testing (SPT or sIgE) undertaken as part of the alence of 54 % and a self-reported tree nut allergy prevalence of
study in the absence of a formal food challenge. 9.16 % (95% CI 6.8–11.9) [24]. This study has been included in
2. Probable tree nut allergy—defined as reported history the summary table, but the prevalence estimates not discussed as
(>2 years) of IgE-mediated reaction with allergy or self- part of the review since the participation rate was extremely low
report of doctor diagnosis (presumed to include allergy- and the study therefore not necessarily representative of the
specific history and testing). population from which it was sampled.
3. Self-reported tree nut allergy—defined as parent or self- The random effects meta-analysis showed heterogeneity to
reported tree nut allergy in the absence of data on allergy be too great to report pooled results (I2 >98 %, p=0.000 for all
testing. analyses).
4. Sensitisation only (allergy testing via SPT or sIgE, with-
out confirmation of clinical allergy). Tree Nut Allergy Prevalence by Age and Allergy Diagnosis
Method
We performed a random effects meta-analysis and in an
attempt to address the significant heterogeneity observed The majority (n=24) of studies in this review were in children
across the studies stratified by age, region and method of tree and adolescents, four studies included both adults and chil-
nut allergy diagnosis. Statistical analyses were undertaken dren, six studies adults only and two studies reported an over-
using STATA 13 (Stata Corp, College Station, TX, USA). all tree nut allergy prevalence without age breakdown; in one
of these studies, participants were >15 years [23] and the
second <61 years of age [25].
Results Prevalence estimate ranges for all allergy definitions,
categorised by age, are outlined in Table 2. Seven studies used
Study Selection and Characteristics the most objective assessment of oral food challenge (or convinc-
ing recent history of allergic reaction together with positive
Figure 1 summarises the search methodology. The systematic allergen-specific IgE) with an overall prevalence range of 0–
search of the literature resulted in 333 articles after duplicates 1.6 %. Nine studies combined self-reported food allergy with
were removed. Title and abstract review identified 261 that additional objective assessment such as specific details regarding
did not meet the inclusion criteria. The remaining 72 articles doctor diagnosis or sensitisation details (sIgE/SPT) and were
and an additional ten records identified through manually classified as probable food allergy for this review. The overall
searching reference lists underwent full-text review. Forty probable tree nut allergy prevalence range was 0.05–4.9 %, with
six full-text articles were excluded (26 were in selected popu- only one study reporting adult data. However, the majority of
lations, seven did not report tree nut allergy prevalence, seven prevalence estimates for tree nut allergy were based on self-
did not include prevalence data and six were review articles). reported reactions (n=20 studies). The self-reported tree nut al-
Included studies are described in Table 1 (n=36).Twenty lergy prevalence range was wider for adults (0.18–8.9 %) and
six studies were designed to measure overall food allergy those studies including both adults and children (0.4–11.4 %)
prevalence and reported tree nut allergy as a study outcome, than those studies including only children (0–3.8 %). Overall
seven were studies specifically aimed at investigating tree nut self-reported tree nut allergy prevalence ranged from 0 to 11.4 %.
allergy prevalence and three studies included tree nut allergy Three studies based tree nut allergy prevalence on sensiti-
prevalence data as part of an investigation of peanut allergy sation alone (sIgE or SPT) without any clarification of pres-
prevalence or associated factors. ence of clinical allergy. One reported hazelnut sensitisation by
Quality assessment of the studies based on participation rate, SPT in Russian children of 0.8 % (95 % CI 0.4–1.1) and
ability of the study design to address tree nut allergy outcomes Finnish children of 6.3 % (95% CI 3.6–9.8) [52]. The second
objectively and inclusion of individual tree nut information re- study reported sensitisation based on SPT of 1.0 % in 7-year-
sulted in 28 studies graded as moderate and eight poor. Three of old children in the UK [40]. The third study in adults reported
the studies were assessed as poor because they were not de- sensitisation prevalence to hazelnut of 9.26 % and walnut
signed to measure tree nut allergy prevalence but reported some 2.98 % (overall 12.2 % (95% CI 11.7–12.7)) [20]. This was
Table 1 Summary of the characteristics of studies in review: studies published January 1, 1996–Dec 31, 2014 (alphabetical by author)

Reference Country Study design Allergy outcome Type of allergy N Participation Age Individual Prevalence Overall prevalence Study
rate (%) tree nuts measure % (95 % CI) (N) grading
described

Ahn et al. 2012 [17] Korea Cross- 2. Probable (self- Primary and 7882 97 6–13 years NA Point and 0.05 % (0.01–0.13) Moderate
sectional report of Dr secondary lifetime (4/7882)
diagnosis and sIgE)
Bedolla-Barajas Mexico Cross- 1. Self-report Primary and 1126 NA 18–50 years Yes Point 0.18 % (0.02–0.64) Poor
et al. 2014 [18] sectional secondary (2/1126)
Ben-Shoshan et Canada Cross- 1. Self-report Primary and 9667 34.6 All ages with NA Point Children 1.1.73 Moderate
al. 2010 [19] sectional 2. Probable (self- secondary breakdown (1.16–2.3)
Curr Allergy Asthma Rep (2015) 15: 54

report of Dr 2.0.69 (0.4–0.97)

diagnosis and sIgE) Adults: 1. 1.07
(0.84–1.30)
2. 0.35 (0.27–0.44)
Overall: 1. 1.22 %
(1.00–1.44)
(118/9667)
2. 0.68 %
(0.54–0.83)
Burney et al. Multi Cross- 4. Sensitisation Primary and 17,366 54.9 20–54 years Yes Point 12.2 % (11.7–12.7) Moderate
2014 [20] (Europe) sectional (sIgE) secondary (2121/17326)
Caffarelli et al. Italy Cross- 1. Self-report Primary and 625 69 5–14 years Yes 0.32 % (0.04–1.2) Moderate
2011 [21] sectional secondary (2/625)
DuToit et al. UK Cross- 1. Self-report Primary 4148 (UK) 80.2 (UK) 4–18 years NA Point UK 1.85 % (1.5–2.3) Moderate
2008 [22] Israel sectional 4672 (Israel) 83.2 (Israel) (77/4148)
Israel 0.13 %
(0.05–0.3)
(6/4672)
Emmett et al. UK Cross- 1. Self-report NA 16,434 NA All ages NA Point 0.40 % (0.30–0.51) Moderate
1999 [23] sectional (63/16,434)
Greenhawt et. al. USA Cross- 1. Self-report NA 571 3.5 >18 years NA Point 9.16 % (6.8–11.9) Poor
2009 [24] sectional (47/571)
Kanny et al. France Cross- 1. Self-report Primary and 16,174 52 All ages NA Point 3 % (2.7–3.20) Moderate
2002 [25] sectional secondary <60
Kaya et al. Turkey Cross- 1. Self-report Primary 10,096 89.9 11–15 years Yes Lifetime 1.1.2 % (0.1–1.4) Moderate
2013 [26] sectional 3. Confirmed (121/10,096)
(DBPCFC) 3.0.05 % (0.02–0.1)
(6/100,096)
Kljakovic et al. Australia Cross- 1. Self-report NA 3851 85 4–5 years No Lifetime 1.79 % (1.4–2.3) Poor
2009 [27] sectional (69/3851)
Kristjansson Sweden Cross- 1. Self-report NA 324 79 (Iceland) 18 months No Point 1. Sweden 0.3 % Moderate
et al. 1999 [28] Iceland sectional 3. Confirmed (Iceland) 90 (Sweden) (0.0–1.6) (1/328)
(OFC) 328 Iceland 0 %
(Sweden) 3.0 % for Iceland
and Sweden
Page 5 of 13 54
Table 1 (continued)

Reference Country Study design Allergy outcome Type of allergy N Participation Age Individual Prevalence Overall prevalence Study
rate (%) tree nuts measure % (95 % CI) (N) grading
described
54 Page 6 of 13

Leung et al. 2009 Hong Kong Cross- 1. Self-report Primary and 3677 83.6 % 2–7 years NA NA 1. 0.41 (0.2–0.7) Moderate
[29] sectional 2. Probable (self- secondary (15/3677)
report of Dr 2. 0.3 % (0.2–0.5)
diagnosis) (11/3677)
Marklund et al. Sweden Cross- 1. Self-report Primary and 1451 97 13–21 years NA Point 11.37 % (9.5–12.8) Moderate
2004 [30] sectional secondary (165/1451)
Mustafayev et al. Turkey Cross- 1. Self-report Primary 6963 NA 10–11 years Yes Point 1.3.5 % (3.1,3.9) Moderate
2012 [31] sectional 2. Probable (detailed (223/6963)
history and SPT) 2.4.9 % (4.4,5.4)
3. Confirmed (OFC) (341/6963)
3.0.05 % (0.03,0.15)
(4/6963)
Nicolaou et al. UK Cohort 1. Self-report Primary 1029 94.9 8 years NA Lifetime 1.0 % (0.4,1.8) Poor
2010 [32] (10/1029)
Orhan et al. Turkey Cross- 1. Self-report Primary 2739 78.2 6–9 years Almond Point 1.0.4 % (0.2,0.7) Moderate
2009 [33] sectional 2. Probable (SPT) and (11/2739)
3. Confirmed (OFC) walnut 2.0.14 % (0.03,0.4)
(4/2739)
3.0 % (0,0.1) (0/2739)
Ostblom et al. Sweden Cohort 1. Self-report Primary 2563 69 4 years NA Point 3.8 % (3.1,4.6) Moderate
2008 [34] (98/2563)
Osterballe et al. Denmark Cohort 1. Self-report Specified primary 843 77 22 years Yes Point 1. Primary 0 % Moderate
2009 [35] and secondary Secondary 8.9 %
(7.0,11.02)
(85/843)
Penard-Morand France Cross- 1. Self-report Primary and 7781 81 9–11 years NA Lifetime 0.2 % (0.1,0.3) Moderate
et al. 2005 [36] sectional secondary (10/6672)
Pereira et al. UK Cohort 1. Self-report Primary and 1532 48.7 11 and NA Point 1.6 % (1.1,2.4) Poor
2005 [37] secondary 15 years (26/1532)
Pyrhonen et al. Finland Cross- 1. Self-report Primary and 3308 69 1–4 years NA Lifetime 1.1.5 % (1.1,1.9) Moderate
2005 [38] sectional 2. Probable (self- secondary (49/3308)
report of Dr 2.0.2 % (0.08,0.4)
diagnosis) (7/3308)
Rance et al. France Cross- 1. Self-report Primary and 2716 77.6 2–14 years Yes Point 0.7 % (0.4,1.1) Moderate
2005 [39] sectional secondary (19/2716)
Roberts et al. UK Cohort 4. Sensitisation Sensitisation 5848 42 7 years Yes Point 1.04 % (0.8,1.3) Poor
2005 [40] (SPT) only (61/5848)
Roehr et al. Germany Cross- 1. Self-report Primary and 739 31.5 0–17 years Yes Point 1. NA Moderate
2004 [41] sectional 2. Probable (SPT) secondary 2. 2.7 % (1.6,4.1)
3. Confirmed (OFC) (20/739)
3. 1.4 % (0.7,2.5)
(10/739)
Curr Allergy Asthma Rep (2015) 15: 54
Table 1 (continued)

Reference Country Study design Allergy outcome Type of allergy N Participation Age Individual Prevalence Overall prevalence Study
rate (%) tree nuts measure % (95 % CI) (N) grading
described

Schafer et al. Germany Cross- 1. Self-report Primary and 1537 60.7 25–74 years NA Point 1.8.5 % (7.1,9.9) Moderate
2001 [42] sectional SPT for hazelnut secondary (130/1537)
only
Shek et al. Singapore Cross- 1. Self-report Primary 25,692 74.2 4–6 years and NA Point 1.1.85 % (1.6,2.1) Moderate
2010 [43] Philippines sectional 2. Probable (self- 14–16 years (200/10775)
report of Dr 2.0.28 % (0.2,0.4)
diagnosis) (31/10,775)
Curr Allergy Asthma Rep (2015) 15: 54

Sicherer et al. USA Cross- 1. Self-report Primary and 4374 62 All ages with Yes Point Children (<18 years) Moderate
1999 [44•] sectional secondary breakdown 0.2 % (0.05,0.4)
(5/2998)
Adults (>18 yrs)
0.7 % (0.5,0.9)
(59/8049)
Overall 0.5 %
(0.0,0.6)
(64/12032)
Sicherer et al. USA Cross- 1. Self-report Primary and 13,493 52 All ages with Yes Point Children (<18 years) Moderate
2003 [45•] sectional secondary breakdown 0.2 % (0.1,0.4)
(7/3127)
Adults (>18 years)
0.1 % (0.4,0.6)
(50/9881)
Overall 0.4 %
(0.3,0.5)
(57/13,493)
Sicherer et al. USA Cross- 1. Self-report Primary and 5300 42 All ages with Yes Point Children (<18 years) Moderate
2010 [46•] sectional secondary breakdown 1.1 % (0.05,0.4)
(31/2902)
Adults (>18 years)
0.5 % (0.4,0.6)
(53/9845)
Overall 0.6 %
(0.5,0.8)
(84/12,658)
Tariq et al. UK Cohort 1. Self-report Some Primary 1218 NA 4 years NA Point 0.1 % (0.02,0.6) Poor
1996 [47] participants had (2/1218)
SPT
Taylor-Black USA Cross- 1. Self-report Primary 368 43 4–12 years NA Point 1.82 % (1.06,2.9) Poor
et al. 2014 [48] sectional (17/932)
Venter et al. UK Cohort 1. Self-report Primary 798 55.4 6 years Yes Point 1. 1.37 % (0.8,2.5) Moderate
2006 [49] 3. Confirmed (OFC) (11/798)
3. 0.25 % (0.03,0.9)
(2/798)
Page 7 of 13 54
54 Page 8 of 13 Curr Allergy Asthma Rep (2015) 15: 54

Moderate

Moderate

Moderate
the highest reported prevalence estimate of all four methods of

grading
Study tree nut allergy definition.

Tree Nut Allergy Prevalence by Region

3.0.93 % (0.34,2.0)

1.0.65 % (0.43,0.9)

2.0.5 % (0.06,0.32)
Individual Prevalence Overall prevalence
% (95 % CI) (N)

Finland 6.3 %
Prevalence estimate ranges for each method of allergy defini-

Russia 0.8 %
(29/4477)

(7/4477)

(17/271)
(3.6,9.8)

(0.2,2.4)
(6/642)

(3/356)
tion are summarised by region in Table 3. Regional variation
in self-reported tree nut allergy prevalence is illustrated in
Fig. 2. Most studies were from Europe (n=18), the UK (n=
8), or the USA (n=5). There were three studies from Asia and
tree nuts measure

one each from Canada, Central America and Australia. Strat-

Point
Point

Point

ifying by region highlighted a markedly higher prevalence of

tree nut allergy in some European countries with a range of
described

Hazelnut

0.04–11.4 %. OAS appeared to contribute to higher tree nut

only

allergy prevalence in some European countries since all three

Yes

NA

of the studies reporting tree nut allergy prevalence over 8 %

were self-reported, all in adolescents and adults, and all from
7–16 years
>18 years

Europe. Two of these studies directly reported that all tree nut
3 years

allergy found in their study was due to OAS [35, 42] and the
Participation Age

third study did not specify the type of allergic reaction to tree
nuts, but overall 33 % of all allergy, to any food, was report-
edly due to OAS [30]. All other regions, regardless of allergy
rate (%)

definition, reported tree nut allergy prevalence less than 2 %.

91.9

NA
NA

Individual Tree Nut Allergy Prevalence

Finland 367
Russia 446

Table 4 summarises the percentage of tree nut allergic partic-

4482
891
N

ipants allergic to each individual tree nut by region. Fourteen

studies provided details of individual tree nut prevalence. The
Type of allergy

prevalence of individual tree nut allergies varied by region.

secondary
Primary and

Hazelnut was the most common tree nut allergy reported in six
Primary

Primary

of the seven studies from Europe accounting for 17–100 % of

all tree nut allergies. The two studies from the USA reported
walnut and cashew as the most common tree nut allergies
3. Confirmed (OFC)

ranging from 20 to 30 % and 15–30 %, respectively. Brazil

2. Probable (self-
Study design Allergy outcome

nut allergy was reported commonly in the UK ranging from

4. Sensitisation
report of Dr
1. Self-report

1. Self-report

diagnosis)

24 to 33 %. The one study from Mexico reported low overall

(SPT)

tree nut allergy of 0.18 % (2/1126) with both participants

allergic to walnut. None of the studies reported on the preva-
lence of multiple tree nut allergies.
sectional

sectional

Tree Nut Allergy Prevalence Over Time

Cohort

Cross-
Cross-

There is limited evidence to determine if the population

prevalence of tree nut allergy is increasing. Three studies
Country

Finland
Russia

in the USA utilised random-digit telephone surveys in

USA
UK

1997, 2002 and 2008 [44•, 45•, 46•]. Study design was
consistent across each sampling period and included a
Table 1 (continued)

large number of participants (n=4374; 13,493 and 5300,

respectively). No significant increase in adult self-reported
et al. 2006
Von Hertzen
2008 [50]

2007 [51]
Venter et al

Vierk et al.
Reference

tree nut allergy prevalence was found over the three time
[52]

points. However, the prevalence of self-reported tree nut

allergy in children younger than 18 years had increased
Curr Allergy Asthma Rep (2015) 15: 54 Page 9 of 13 54

Table 2 Summary of the range of

prevalence estimates of tree nut Allergy definition and age Number Range of prevalence References
allergy in the reviewed studies of studies estimates (%)
according to allergy assessment
method and age Self-reported
Children 0–18 years 22 0–3.8 [21, 22, 26–29, 31–34, 36–39, 43,
Adult 8 0.18–8.9 44•, 45•, 46•, 47–49, 53]
All ages 3 0.4–11.4 [18, 35, 42, 44•, 45•, 46•, 51, 53]
Overall 0–11.4 [23, 25, 30]
Probable
Children 0–18 years 9 0.05–4.9 [17, 19, 29, 31, 33, 38, 41, 43, 51]
Adult 2 0.35–0.5 [19, 51]
All ages 0 NA
Overall 0.05–4.9
Confirmed
Children 0–18 years 7 0–1.4 [26, 28, 31, 33, 41, 49, 50]
Adult 0 NA
All ages 0 NA
Overall 0–1.4
Sensitisation
Children 0–18 years 2 0.8–6.3 [40, 52]
Adult 1 12.2 [20]
All ages 0 NA
Overall 0.8–12.2

Some studies are included in more than one category as they reported prevalence estimates obtained using more
than one allergy assessment method.

significantly (0.2 % in 1997, 0.5 % in 2002 and 1.1 % in observed for peanut over the same time periods (0.4 % in
2008). Proportionally, the increase was greater than that 1997, 0.8 % in 2002 and 1.4 % in 2008).

Table 3 Summary of the range of reported prevalence estimates for tree nut allergy according to allergy assessment method and region

Region Self-report Probable Confirmed Sensitisation

Range % Range % Range % Range %
(number of studies) (number of studies) (number of studies) (number of studies)

Asia Children 0.3–1.85 (3) 0.05–0.3 (3) NA NA

Adults NA NA NA NA
Overall 0.3–1.85 0.05–0.3 NA NA
Europe Children 0.04–3.1 (10) 0.2–4.9 (4) 0–1.4 (6) 0.8 (1)
Adults 8.5–8.9 (2) 1.6 (1) NA 12.2 (1)
All ages 3.0–11.7 NA NA NA
Overall 0.04–11.7 0.2–4.9 0–1.4 0.8–12.2
UK Children 0.1–1.85 (5) NA 0.25–0.93 (2) NA
Adults NA NA NA NA
Overall 0.1–1.85 0.25–0.93
USA Children 0.2–1.82 (4) NA NA NA
Adults 0.5–0.7 (2) NA NA NA
Overall 0.2–1.82
Australia Children 1.79 (1) NA NA NA
Adults NA NA NA NA
Overall
Canada Children 1.73 (1) 1.59 (1) 0.69 (1) NA
Adults 1.07 (1) 1.0 (1) 0.35 (1) NA
Overall 1.07–1.73 1.0–1.59 0.35–0.69
Central America Children NA NA NA NA
Adults 0.02 (1) NA NA NA
Overall
54 Page 10 of 13 Curr Allergy Asthma Rep (2015) 15: 54

Fig. 2 Overall tree nut allergy

prevalence by region (%)

Table 4 Percentage of tree nut allergics reporting reactions to the individual tree nuts by region

Region, study details (country) % of tree nut allergics reporting reactions to the individual tree nuts (number with specific tree nut
allergy/total number with any tree nut allergy)

Europe
Burney et al. 2014 [20] (multi-country) Hazelnut 76 % (1605/2121), walnut 24 % (517/2121)
Caffarelli et al. 2011 [21] (Italy) Hazelnut 100 % (2/2)
Mustafayev et al. 2012 [31] (Turkey) Hazelnut 42 % (104/243), walnut 34 % (83/243), pistachio 22 % (55/243)
Kaya et al. 2013 [26] (Turkey) Walnut 66 % (4/6), hazelnut 17 % (1/6), pistachio 17 % (1/6)
Osterballe et al. 2009 [35] (Denmark) Hazelnut 75 % (56/75), Brazil nut 31 % (23/75), walnut 5 % (4/75), almond 3 % 2/75)
Rance et al. 2005 [39] (France) Hazelnut 53 % (10/19), walnut 32 % (6/19), almond 10 % (2/19), cashew 5 % (1/19)
Roehr et al. 2004 [41] (Germany) Hazelnut 100 % (10/10)
USA
Sicherer et al. 1999 [44•] Walnut 37 % (24/65), cashew 12 % (5/65), Brazil nut 12 % (8/65), almond 11 % (7/65),
Sicherer et al. 2010 [46•] pecan 11 % (7/65), hazelnut 4.6 % (3/65), macadamia 3 % (2/65), unspecified 9 % (6/65)
Walnut 48 % (41/84), cashew 34 % (29/84), pecan 30 % (26/84), almond 29 % (25/84),
pistachio 22 % (19/84), Brazil nut 22 % (19/84), hazelnut 20 % (17/84),
macadamia 20 % (17/84), pine nut 13 % (11/84)
UK
Venter et al. 2008 [50] Brazil nut 33 % (2/6), almond 33 % (2/6), hazelnut 17 % (1/6), cashew 17 % (1/6)
Venter et al. 2006 [49] Almond 33 % (1/3), Brazil nut 33 % (1/3), hazelnut 33 % (1/3)
Roberts et al. 2005 [40] Walnut 24 % (10/41), Brazil nut 24 % (10/41), almond 22 % (9/41), cashew 15 % (10/41),
Tariq et al. 1996 [47] hazelnut 7 % (3/41), pecan 7 % (3/41)
Hazelnut 50 % (1/2), cashew 50 % (1/2)
Mexico
Bedolla-Barajas et al. 2014 [18] Walnut 100 % (2/2)
Curr Allergy Asthma Rep (2015) 15: 54 Page 11 of 13 54

Discussion variation in dietary patterns at the population level might lead

to variations in sensitisation status and hence risk of subse-
This review has confirmed that the majority of tree nut allergy quent food allergy. Du Toit et al. hypothesised that variations
prevalence studies continue to be undertaken in Europe, where in peanut allergy prevalence between genetically similar pop-
there is a high prevalence of OAS, with most studies relying ulations in the UK and Israel might be due to differences in
on self-reported prevalence, limited to children and adoles- infantile peanut consumption patterns [22], whilst others have
cents. Using the most robust measure of tree nut prevalence argued that boiled versus roasted peanut dietary intakes may at
(challenge confirmed or history of reaction with IgE antibod- least partly explain the difference in allergy patterns across
ies), we estimate the overall prevalence to be <2 % in coun- different regions [56, 57].
tries where OAS is not reported. Secondary tree nut allergy Our review found a higher self-reported tree nut allergy
(OAS) estimates for older age groups including adolescents range (0–11.4 %) than both previous published systematic
and adults is as high as 10 %, particularly in Europe. Few reviews. Nwaru et al. performed a meta-analysis of seven
studies reported the population prevalence of individual tree studies and reported a pooled self-reported point prevalence
nut allergies. However, how prevalent a particular tree nut of 1.8 % (95% CI 1.63–1.99), although there was signifi-
allergy is differs significantly by region with hazelnut the most cant heterogeneity across the studies (I2 =99.4 %, p=0.00).
common tree nut allergy in Europe, walnut and cashew in the Zuidmeer et al. included studies from a wider range of
USA and Brazil nut, almond and walnut most commonly re- countries from 1990 to 2006 and reported a self-reported
ported in the UK. There is limited evidence to determine if the tree nut allergy prevalence range of 0–7.3 % based on
population prevalence of tree nut allergy is increasing. seven studies [12•]. Prevalence varied based on type of tree
This is the first systematic review of the literature exploring nut allergy, method of tree nut allergy diagnosis, age and
tree nut allergy prevalence exclusively across the age groups region. Similarly to Zudimeer et al., considering the large
and different regions of the world, utilising robust systematic heterogeneity between the studies, we have not presented a
review methodology, closely following PRISMA guidelines. pooled prevalence estimate since this would mask the dif-
A further strength of this review is we categorised prevalence ferences between populations.
by robustness of the study methodology employed to define Nwaru et al. reported confirmed tree nut allergy pooled
tree nut allergy. We identified three studies with self-reported point prevalence of 0.45 % (I2 = 0.00 %, p = 0.88) while
tree nut allergy greater than 8 %, all from Europe demonstrat- Zuidmeer et al. reported a range of 0.1–4.3, based on only
ing that studies which do not differentiate primary and sec- three studies. We found the prevalence of tree nut sensitisation
ondary tree nut allergy prevalence rates are likely to inflate to be the highest of the four methods of allergy definition used
prevalence estimates. (1.0–12.2 %). Comparison to sensitisation prevalence esti-
Precise estimates of true tree nut allergy were limited by the mates in previous reviews is difficult as we reported sensitisa-
small number of studies reporting challenge confirmed tree tion prevalence estimates based on population sensitisation.
nut allergy prevalence—the gold standard for diagnosis. As Previous reviews both reported studies where SPT or sIgE
for other epidemiological studies of food allergy prevalence was performed only on participants that had previously self-
[8•, 9], we also found higher prevalence estimates for self- reported tree nut allergy. Neither of these reviews differentiat-
report and sensitisation. Self-report is known to overestimate ed between primary and secondary tree nut allergy prevalence,
the true prevalence of food allergy [54] and asymptomatic or reported on individual tree nut allergy prevalence nor the
sensitisation to foods is relatively common [9]; therefore, ob- nature or prevalence of multiple tree nut allergies.
jective measures are critical. We were also unable to accurate- In conclusion, this systematic review has highlighted
ly determine whether tree nut allergy is on the rise as only one that there is considerable heterogeneity in tree nut allergy
series of estimates was available. Finally, estimates of the prevalence from studies to date and pooling individual
prevalence of individual tree nut allergies could not be reliably study estimates risks masking the real differences between
estimated due to the paucity of data reported for individual populations. Data is limited to largely European, US and
nuts, although it is clear that there is significant regional var- UK studies using self-reported prevalence in children and
iation in prevalence estimates [55]. adolescents. There is a need for further studies to deter-
We found overall tree nut allergy prevalence mirrors the mine tree nut allergy by gold standard methodologies
global pattern of overall food allergy with countries with such as food challenge, and differentiate between primary
low prevalence of food allergy also reporting low levels of and secondary tree nut allergy. Further detailed informa-
tree nut allergy. Large population-based epidemiological stud- tion on individual tree nut prevalences will help inform
ies such as the ISAAC and EuroPrevall studies have demon- our understanding of regional variation and repeated esti-
strated considerable regional variability of common food al- mates over time will enable us to understand whether time
lergens and sensitisation patterns, but the reasons for this re- trends in tree nut allergy mirror the general rise in IgE-
main largely unexplored. It has been hypothesised that mediated food allergy reported in developed countries.
54 Page 12 of 13 Curr Allergy Asthma Rep (2015) 15: 54

Acknowledgement This review forms work as part of VMc PhD, EuroPrevall study. This is the first review paper of food allergy
funded by the Centre for Food and Allergy Research (CFAR). prevalence to include tree nut allergy prevalence estimates, but
was limited to Europe.
Compliance with Ethics Guidelines 13.• Nwaru BI, Hickstein L, Panesar SS, Roberts G, Muraro A, Sheikh
A, et al. Prevalence of common food allergies in Europe: a system-
Conflict of Interest Drs McWilliam, Koplin, Lodge, Tang, Dharmage atic review and meta-analysis. Allergy. 2014;69(8):992–1007. This
and Allen declare no conflicts of interest. systematic review and meta-analysis is an update on the
Zuidmeer review which was limited to Europe and is the first
review of worldwide food allergy prevalence to include tree nut
Human and Animal Rights and Informed Consent This article does allergy prevalence estimates.
not contain any studies with human or animal subjects performed by any
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of the authors.
allergy epidemic. Pediatr Allergy Immunol. 2011;22(2):155–60.
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