Beyond Food Avoidance: A More Personalized Approach to Food Allergy Care

For many years, families living with food allergies were given a limited set of instructions: avoid the food, carry epinephrine, and be prepared for an emergency. While these measures remain essential for managing food allergy risk, they do not represent the full range of care that may be available today.

Food allergy treatment has evolved considerably, with approaches such as oral immunotherapy (OIT), sublingual immunotherapy (SLIT), biologic medications, and more advanced diagnostic tools expanding the possibilities for some patients. But having more options also creates an important question: How do we determine which approach is appropriate for each individual?

In this episode of The Immune Edit, Dr. Doug Jones speaks with Dr. Atul Shah, a board-certified pediatric and adult food allergy specialist and founder of the New York Food Allergy and Wellness Program. With more than 20 years of experience, Dr. Shah discusses the evolution of food allergy treatment, the development of his Food Allergy Tolerance Enhancement (FATE) program, and how diagnostic testing, patient preferences, and individualized treatment planning can work together.

Their conversation highlights an important principle: successful food allergy care should not look the same for everyone.

How Food Allergy Treatment Has Evolved

When Dr. Jones and Dr. Shah first began exploring oral immunotherapy, the treatment was still relatively unfamiliar to many clinicians.

Dr. Jones first learned about OIT in 2009, gave it serious consideration in 2012, and began treating his first patient in 2013. Dr. Shah also began treating patients around 2013, although he initially kept the work relatively quiet while developing his experience and confidence with the approach.

At the time, OIT was not widely accepted. Clinicians exploring the treatment often faced skepticism, and some were considered outliers within the allergy community.

OIT, or oral immunotherapy, involves administering carefully controlled, gradually increasing amounts of an allergen under specialist supervision. The aim is to increase the amount of that food a patient can tolerate, reducing the likelihood of reacting to accidental exposure.

As more clinicians began exploring this approach, collaboration became increasingly important. Rather than developing protocols in isolation, Dr. Jones and Dr. Shah began sharing their experiences, learning from one another, and helping other allergists understand how to approach diagnosis, testing, and treatment.

This exchange of knowledge helped support the development of more structured practices and educational opportunities within the food allergy community.

Why Collaboration and Education Matter in Food Allergy Care

The development of new treatment approaches is only one part of improving patient care. Clinicians also need opportunities to share experiences, discuss challenges, and establish practices that prioritize patient safety.

Dr. Jones describes how conversations with fellow board-certified allergists Richard Wasserman and Hugh Sampson helped lead to the development of a nonprofit organization focused on collaboration, patient registries, and best practices in food allergy diagnosis and treatment.

The organization, Food Allergy Support Team (FAST), was established to encourage education, information sharing, and collaboration among professionals working in the field.

An important part of this effort has been helping clinicians understand not only how to introduce treatment approaches such as OIT, but also how to identify appropriate patients, interpret diagnostic information, develop protocols, and recognize potential risks.

This is particularly important when working with treatments that require careful patient selection and ongoing monitoring.

For Dr. Jones and Dr. Shah, the larger goal has always been to help more families access appropriate care while reducing the likelihood of unnecessary risks and poorly implemented treatment approaches.

Why Food Allergy Diagnosis Needs More Than One Test

One of the most important parts of food allergy management is establishing what is actually happening when someone reacts to a food.

A positive allergy test does not automatically mean a person has a clinical food allergy. Skin prick tests and blood tests that measure food-specific immunoglobulin E (IgE) can identify sensitization, but sensitization alone does not establish that eating the food will cause an allergic reaction.

This distinction matters because several different conditions and responses can be grouped under the general label of food allergy, even though they involve different mechanisms and require different approaches.

For example, a patient may have:

• IgE-mediated food allergy: An immune response involving food-specific IgE antibodies that can cause allergic reactions, sometimes including anaphylaxis.
• Food intolerance: A non-immune reaction to a food that may involve difficulty digesting or processing particular substances.
• Food sensitivity: A broad term that is often used inconsistently and does not, by itself, establish a specific immune mechanism.
• Oral allergy syndrome (OAS): A form of pollen-food allergy syndrome in which cross-reactivity between pollen allergens and certain foods can cause symptoms, often involving the mouth and throat.
• Food protein-induced enterocolitis syndrome (FPIES): A non-IgE-mediated food allergy that typically causes delayed gastrointestinal symptoms and can sometimes lead to significant reactions.

These distinctions are important because the diagnosis influences the patient's risk, the need for avoidance, and whether a particular treatment approach is appropriate.

Dr. Jones compares the diagnostic process to investigating a crime scene. A reaction provides clues, but clinicians need to gather and interpret those clues to understand what happened, which mechanism may be responsible, and what the safest next step should be.

Medical history, skin testing, blood testing, component testing, and, when appropriate, an oral food challenge can all contribute to this process.

Basophil Activation Testing: Adding Another Layer to the Diagnostic Picture

One of the diagnostic tools discussed in the episode is the basophil activation test (BAT).

Basophils are white blood cells involved in allergic immune responses. They share important functional similarities with mast cells, which are found in tissues and release substances such as histamine during certain allergic reactions.

The BAT uses a blood sample to examine how a patient's basophils respond when exposed to a particular allergen.

In the laboratory, the cells are stimulated with the food being investigated at different concentrations. Their activation is then measured using laboratory techniques that identify changes in cell-surface markers associated with activation.

Unlike conventional skin prick and food-specific IgE tests, which primarily demonstrate sensitization, BAT provides functional information about how a patient's basophils respond to an allergen.

How Can BAT Help Guide Food Allergy Decisions?

Dr. Shah explains that BAT can provide additional information when conventional testing and a patient's clinical history do not give a clear picture.

It may help clinicians:

• Further assess the likelihood of a clinically relevant allergic response.
• Support decisions about whether an oral food challenge may be appropriate.
• Provide additional information when conventional test results and the patient's history do not align.
• Monitor changes in basophil responsiveness during treatment.

For example, a patient may have elevated conventional allergy test results but show little basophil activation in response to the tested food. In the appropriate clinical context, this information may help an allergist assess whether a supervised oral food challenge is worth considering.

Conversely, substantial basophil activation may provide a reason for additional caution before proceeding with a challenge.

However, BAT is not a standalone diagnostic answer. Its results must be interpreted alongside the patient's medical history, other test results, and clinical presentation. It does not replace an oral food challenge when one is needed to establish whether a patient can safely eat a food.

Can Patients Access BAT Outside New York?

Dr. Shah explains that his laboratory can accept samples from 48 states through arrangements involving the patient's allergist and a laboratory director licensed in those states.

Patients interested in the test generally begin by contacting the practice, which then coordinates with their treating allergist regarding sample collection, testing, and the communication of results.

The important point is that BAT should be incorporated into a broader clinical evaluation rather than used as an independent reason to start or avoid treatment.

The FATE Program: Building Treatment Around the Patient

A central part of Dr. Shah's approach is his Food Allergy Tolerance Enhancement (FATE) program.

The program was developed to make food allergy treatment easier for patients and families to understand. With several treatment approaches and medical acronyms circulating in the field, it can be difficult for families to determine what their options actually mean.

Dr. Shah explains that the central idea behind FATE is to understand a patient's existing level of tolerance and explore how it may be safely enhanced.

He describes the process as having five main phases.

1. Medical History

The process begins with a detailed understanding of the patient's history.

This includes previous reactions, the foods involved, the nature and severity of symptoms, and other relevant clinical information. A patient's history helps guide which investigations may be needed and what questions should be addressed.

2. Diagnostic Testing

The next phase involves appropriate testing to build a clearer picture of the patient's allergic response.

Depending on the individual, this may include skin testing, food-specific IgE testing, component testing, and basophil activation testing.

The goal is not simply to collect positive or negative results. It is to understand how those findings relate to the patient's actual clinical history.

3. Oral Food Challenges, When Appropriate

An oral food challenge may be used when the diagnosis or the patient's ability to tolerate a food remains uncertain.

During a medically supervised challenge, the patient receives gradually increasing amounts of the food under controlled conditions, with appropriate monitoring and emergency preparedness.

Oral food challenges can provide important clinical information, but they must be conducted by qualified professionals who can assess and manage potential reactions.

4. Individualized Treatment

Once the diagnostic picture is clearer, the clinician and patient can consider appropriate treatment options.

Depending on the patient's circumstances, these may include:

• Oral immunotherapy (OIT): Gradually increasing oral exposure to a food allergen under medical supervision.
• Sublingual immunotherapy (SLIT): Administering small amounts of an allergen under the tongue as part of a supervised treatment approach.
• Biologic medications: Medicines that target particular pathways involved in allergic disease and may be considered in selected patients.
• Combination approaches: In certain circumstances, clinicians may consider more than one treatment modality.

Not every approach is suitable for every patient. Treatment selection requires an understanding of the allergy, the patient's medical history, potential risks, and individual goals.

5. Defining the Patient's Goals

The final phase focuses on what the patient actually wants to achieve.

For one family, the priority may be reducing the risk associated with accidental exposure. Another patient may want to explore whether a broader range of foods can eventually be incorporated into their diet.

Patients may also have different preferences regarding whether to address one food or multiple foods.

This is an important part of the FATE approach: treatment decisions should reflect the patient's goals rather than assuming that every individual wants the same outcome.

Desensitization and Food Freedom: Understanding the Difference

One misconception discussed during the episode is that oral immunotherapy cannot help patients move toward more flexible eating.

Dr. Shah emphasizes that treatment has evolved and that some patients can make substantial progress through carefully developed protocols.

To understand what this means, it is important to distinguish between two concepts: desensitization and sustained unresponsiveness.

Desensitization refers to an increased threshold of reactivity while a patient is receiving treatment and maintaining the required dosing. In practical terms, the patient may be able to tolerate a greater amount of the allergen than before treatment.

Sustained unresponsiveness refers to the ability to maintain a period of reduced reactivity after treatment dosing has been stopped for a defined period. This is a different outcome and is not guaranteed by desensitization.

The possibility of eating a food more freely depends on several factors, including the treatment protocol, the patient's response, and whether ongoing dosing or other precautions are required.

It is therefore important not to assume that completing an OIT program automatically means a patient can stop treatment or eat unlimited amounts of the food without risk.

The appropriate goal should be discussed with the treating allergist and clearly defined before treatment begins.

Treating the Food Allergy Is Only Part of the Picture

Another important theme in the conversation is the relationship between food allergy, stress, anxiety, and the nervous system.

Dr. Jones and Dr. Shah agree that the experience of living with food allergy can involve much more than the immune response itself.

For children and adults, food allergy can affect everyday decisions, family routines, social experiences, and the emotional experience of eating. Previous reactions may also contribute to fear and anxiety around particular foods.

Two patients may have similar test results and receive comparable treatment, yet experience different outcomes. Factors such as nutrition, stress, individual circumstances, and emotional well-being may influence how patients experience and navigate treatment.

Dr. Shah describes what he calls psychological desensitization: helping patients gradually become more comfortable with the experience of eating and managing their food allergy.

This does not mean that psychological support replaces medical treatment. Rather, it recognizes that the emotional experience of food allergy deserves attention alongside the biological condition.

The Role of Counseling and Psychological Support

Dr. Shah explains that his practice works with counselors and mental health professionals depending on the needs of the patient and family.

Some professionals have specific experience with food allergy, while others provide broader psychological or psychiatric support.

This can be particularly valuable when a child or family has developed significant anxiety around food, eating, or the possibility of an allergic reaction.

Addressing these concerns can help patients and families navigate treatment with greater confidence and support.

The goal is not to dismiss fear or tell patients that their reactions are simply psychological. It is to recognize that living with a potentially serious food allergy can affect emotional well-being and that appropriate support may be an important part of comprehensive care.

Precision Medicine: Why One Treatment Does Not Fit Everyone

As the conversation expands beyond food allergy, Dr. Jones discusses his work with patients experiencing complex neuroimmune conditions, including myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and Long COVID.

He explains that some of these patients experience difficulties with eating and may have overlapping concerns involving immune function, the nervous system, nutrition, and other physiological processes.

This has reinforced his interest in precision medicine: understanding the individual characteristics of each patient and tailoring care accordingly.

Rather than assuming that one treatment will work for everyone, the aim is to understand which factors may be most relevant for a particular patient.

Potential approaches discussed include immune-modulating medications, biologics, appropriate supplements, lifestyle measures, nutrition, pacing, rest, and recovery.

Dr. Jones also emphasizes the importance of identifying nutritional deficiencies in patients whose symptoms or dietary restrictions make it difficult to obtain adequate nutrition.

These approaches need to be selected according to the patient's clinical circumstances. Supplements, in particular, should not be treated as universally beneficial, and their use should be guided by appropriate clinical assessment rather than unsupported claims.

The broader principle is that the immune system, nervous system, hormonal pathways, and digestive system do not operate in isolation. Understanding how they interact may help clinicians develop more individualized approaches to complex conditions.

Why Shared Decision-Making Matters

A treatment plan is only meaningful if it reflects the patient's medical needs and personal priorities.

Dr. Jones emphasizes that successful care does not necessarily mean achieving the same outcome for everyone. Even the idea of food allergy freedom can mean different things to different families.

Some may prioritize protection against accidental exposure. Others may want to expand their diet or reduce the restrictions that affect daily life.

Clinicians need to understand these differences before recommending a treatment approach.

Shared decision-making allows patients, families, and healthcare professionals to discuss the available options, potential benefits, limitations, and risks together.

It also gives patients the opportunity to ask questions and understand what a treatment can realistically achieve.

The objective is not to fit every patient into the same protocol. It is to identify an approach that makes sense for that individual.

Helping Families Navigate Food Allergy Information

With the amount of health information available online, families can find themselves overwhelmed by conflicting advice and misinformation.

Dr. Shah offers several practical recommendations for navigating this information.

Start With Reliable Sources

Before following advice or considering a treatment, check where the information comes from.

Not every online resource is medically reliable, and not every treatment claim is supported by appropriate evidence.

Patients and families should look for information from qualified healthcare professionals, established medical organizations, and credible educational resources.

Understand the Actual Diagnosis

It is important to establish whether a patient has a confirmed IgE-mediated food allergy or another condition that may cause symptoms after eating.

Food intolerance, food sensitivity, oral allergy syndrome, and FPIES are not interchangeable with IgE-mediated food allergy. They have different mechanisms and may require different management strategies.

A treatment intended for one condition should not automatically be recommended for another.

Ask Questions and Seek Another Opinion When Needed

Patients should feel comfortable asking their clinicians why a particular test or treatment is being recommended, what its potential benefits and risks are, and whether other options are available.

Dr. Shah also encourages families to seek a second or additional opinion when they remain uncertain about a diagnosis or treatment recommendation.

A second opinion can provide another perspective, clarify confusing information, and help patients make more informed decisions.

Making Food Allergy Education More Accessible

Alongside clinical care, Dr. Shah emphasizes the importance of making food allergy education accessible to children and families.

His practice website, New York Food Allergy and Wellness, provides educational resources, including information about individual foods and the diagnostic process.

The practice has also developed a free educational gaming experience at nyfoodallergy.com/game.

The platform includes six game modes designed to help children and families learn through interactive activities. Topics include reading food labels and understanding when and how to use an epinephrine autoinjector.

The idea is to make important information easier to understand and remember, particularly for younger patients who may benefit from learning through play.

Education is an important part of food allergy management because patients and families need more than a diagnosis. They also need the knowledge and confidence to navigate everyday situations safely.

Moving Toward More Individualized Food Allergy Care

Food allergy treatment has come a long way from the limited options many families were once offered. Advances in immunotherapy, diagnostic testing, biologic medications, and clinical collaboration have created more opportunities to support patients.

But progress is not simply about having more treatments available. It is also about understanding who may benefit from each approach, recognizing the limitations of testing, and making decisions that reflect the individual patient's needs.

The conversation between Dr. Jones and Dr. Shah highlights the importance of collaboration, precision medicine, psychological support, patient education, and shared decision-making.

As our understanding of the immune system, nervous system, hormones, and gut continues to develop, there may be further opportunities to improve how food allergy and other complex conditions are managed.

Ultimately, the goal is not to promise the same outcome for everyone. It is to give each patient a clearer understanding of their options and a treatment approach that reflects their diagnosis, circumstances, and goals.

Frequently Asked Questions

What is oral immunotherapy (OIT) for food allergies?

Oral immunotherapy is a treatment approach in which a patient receives carefully controlled, gradually increasing amounts of a food allergen under medical supervision. The aim is to increase the amount of the food the patient can tolerate and reduce the risk associated with accidental exposure.

What is the difference between food allergy and food sensitivity?

A food allergy involves an immune response to a food. IgE-mediated food allergies can cause reactions ranging from mild symptoms to anaphylaxis. Food sensitivity is a broader term that is often used inconsistently and does not establish a specific immune mechanism. Food intolerance generally refers to a non-immune reaction to a food. Accurate diagnosis is important because these conditions require different management approaches.

What is basophil activation testing (BAT)?

BAT is a laboratory test that uses a blood sample to assess how a patient's basophils respond when exposed to a particular allergen. It provides functional information that may complement conventional allergy testing and help clinicians assess allergic responses. It must be interpreted alongside clinical history and other diagnostic information.

Does a positive IgE test mean someone has a food allergy?

Not necessarily. A positive food-specific IgE result indicates sensitization, but it does not automatically confirm that eating the food will cause an allergic reaction. The result must be interpreted alongside the patient's history and other clinical findings. An oral food challenge may be needed when the diagnosis remains uncertain.

What is the FATE program?

FATE stands for Food Allergy Tolerance Enhancement. It is Dr. Atul Shah's approach to organizing food allergy evaluation and treatment around the patient's history, diagnostic testing, oral food challenges when appropriate, individualized treatment options, and personal goals.

Can oral immunotherapy lead to food freedom?

Some patients may achieve greater dietary flexibility through oral immunotherapy, but outcomes vary. Desensitization generally depends on continued treatment dosing, while sustained unresponsiveness refers to maintaining reduced reactivity after treatment has been stopped for a defined period. Neither outcome should be assumed or guaranteed. Patients should discuss their goals and ongoing precautions with their treating allergist.

Does stress affect food allergy treatment?

Stress and anxiety can influence how patients experience food allergy and navigate treatment. They may contribute to fear around eating and affect a patient's emotional well-being. Psychological support can be helpful alongside appropriate medical care, but it does not replace the diagnosis or treatment of the underlying allergy.

Should every person with food allergy receive immunotherapy?

No. Immunotherapy is not appropriate for every patient or every type of food-related condition. Treatment decisions depend on the confirmed diagnosis, clinical history, individual risks, and patient preferences. An allergist experienced in food allergy management can help determine whether a particular approach is appropriate.

Medical Disclaimer: This article is for educational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment. It reflects the discussion and opinions shared by Dr. Doug Jones and Dr. Atul Shah on The Immune Edit. Treatment options, eligibility, and outcomes vary between individuals. Always consult a qualified healthcare professional before making decisions about food allergy testing, treatment, or dietary changes.

‍