Dietary intakes of monounsaturated fatty acids and risk of mortality from all causes,cardiovascular disease and cancer: A systematic review and dose-response meta-analysis of prospective cohort studies

BackgroundFindings on the link between dietary intakes of monounsaturated fatty acids (MUFA) and risk of mortality are conflicting. This study aimed to summarize existing literature regarding the association between MUFA intake and risk of mortality from all causes, cardiovascular diseases (CVDs), and cancer.MethodsPubMed, Scopus, and ISI Web of Science was systematically searched up to December 2020. Prospective cohort studies which investigated MUFA intake in relation to mortality from all causes, CVD, or cancer were eligible for this systematic review. Publications that had reported risk ratios (RRs) or hazard ratios (HRs) and 95% confidence intervals (CIs) as effect size, were considered.ResultsA total of 17 prospective cohort studies were included. These studies included 1022,321 participants aged ≥ 20 years in total, and 191,283 all-cause deaths, 55,437 CVD deaths, and 64,448 cancer deaths were totally reported. Combining 15 effect sizes from 11 studies, MUFA intake was inversely associated with risk of all-cause mortality (RR: 0.94; 95% CI: 0.90, 0.98; I² =55.5; P = 0.005). Based on 17 effect sizes from 11 studies, we found no significant association between MUFA intake and risk of CVD mortality (RR: 0.95; 95% CI: 0.89, 1.01; I² =37.0; P = 0.06). Combining 10 effect sizes from 6 studies, MUFA intake was not significantly associated with cancer mortality (RR: 0.99; 95% CI: 0.96, 1.03, I² =13.3%, P = 0.32). Also, an additional 5% of energy from MUFA was associated with a 3% reduced risk of all-cause mortality (RR: 0.97; 95%CI: 0.96, 0.98), but not with CVD (RR: 0.98; 95%CI: 0.95, 1.01) and cancer mortality (RR: 0.99; 95%CI: 0.97, 1.01).ConclusionsMUFA intake was found to be inversely associated with risk of all-cause mortality. However, no link was found between MUFA consumption and mortality from CVD or cancer.     

Recent Insights Into Cardiovascular Disease (CVD) Risk Among HIV-Infected Adults

While mortality rates related to cardiovascular disease (CVD) have decreased over time among adults with HIV, excess risk of CVD in the HIV-infected population may persist despite highly active antiretroviral therapy (HAART) treatment and aggressive CVD risk factor control. Beyond atherosclerotic CVD, recent studies suggest that HIV infection may be associated with left ventricular systolic and diastolic function, interstitial myocardial fibrosis, and increased cardiac fat infiltration. Thus, with the increasing average age of the HIV-infected population, heart failure and arrhythmic disorders may soon rival coronary artery disease as the most prevalent forms of CVD. Finally, the question of whether HIV infection should be considered in clinical risk stratification has never been resolved, and this question has assumed new importance with recent changes to lipid treatment guidelines for prevention of CVD.     

Dietary intake of unsaturated fatty acids and age-related cognitive decline: a 8.5-year follow-up of the Italian Longitudinal Study on Aging

There is evidence from a population-based study of an inverse relationship between monounsaturated fatty acids (MUFA) energy intake and age-related cognitive decline (ARCD), while high polyunsaturated fatty acids (PUFA) intake was positively associated with cognitive impairment in elderly subjects. We investigated the possible role of MUFA and PUFA on age-related cognitive changes. A population-based, prospective study was carried out on 278, 186, and 95 nondemented elderly subjects (65-84 years) evaluated for global cognitive functions (Mini-Mental State Examination, MMSE) at the first (1992-1993), second (1995-1996), and third survey (2000-2001), respectively, from the randomized cohort of Casamassima, Bari, Italy (n=704), one of the eight centers of the Italian Longitudinal Study on Aging (ILSA). MUFA and PUFA intakes were assessed at baseline with a semi-quantitative food frequency questionnaire. High MUFA and PUFA energy intakes and total energy intake were significantly associated with a better cognitive performance in a 8.5-year follow-up. In this prospective population-based study on older nondemented subjects with a typical Mediterranean diet, high MUFA and PUFA intakes appeared to be protective against ARCD.     

Inflammation: a pivotal link between autoimmune diseases and atherosclerosis

Premature coronary heart disease has emerged as a major cause of morbidity and mortality in systemic autoimmune diseases. Recent epidemiologic and pathogenesis studies have suggested a great deal in common between the pathogenesis of prototypic autoimmune disease such as rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) and that of atherosclerosis. Some of the most remarkable data in support of a link between autoimmunity and atherosclerosis comes from epidemiological studies of patients with autoimmune disorders (RA and SLE). Many epidemiologic observations have linked systemic inflammation with the cardiovascular events in autoimmune disease such as RA and SLE. Inflammation is increasingly being considered central to the pathogenesis of atherosclerosis and an important risk factor for vascular disease. Systemic inflammation may be regarded as accelerating the atherosclerotic process. Systemic levels of soluble inflammatory mediators such as C-reactive protein (CRP) have been associated with cardiovascular risk in the general population. CRP, or more specifically high sensitivity-hsCRP, is a marker of systemic inflammation that has been identified as a valid biomarker of cardiovascular risk. Furthermore, the immunomodulatory and anti-inflammatory actions of statins may affect their utility in the context of chronic inflammatory autoimmune disease. Thus, effective control or dampening of inflammation, with such agents, should be included in the therapeutic armamentarium of autoimmune diseases with the aim of protecting against cardiovascular disease.     

Frailty and cognitive impairment—A review of the evidence and causal mechanisms

Incidence rates of cognitive impairment and dementia are rising with the ageing population. Meanwhile, the limited success of current treatments has led to a search for early markers of dementia which could predict future progression or improve quality of life for those already suffering from the disease. One focus has been on the correlation between physical and cognitive measures with an increasing interest in the association between frailty and cognitive decline. Frailty is an age-related syndrome described as the decreased ability of an organism to respond to stressors. A number of epidemiological studies have reported that frailty increases the risk of future cognitive decline and that cognitive impairment increases the risk of frailty suggesting that cognition and frailty interact within a cycle of decline associated with ageing. This paper reviews the evidence for an association between frailty and cognitive impairment and outlines some of the mechanisms that potentially underpin this relationship from brain neuropathology and hormonal dysregulation to cardiovascular risk and psychological factors.     

Effects of seasonal mood changes on seasonal variations in coronary heart disease: role of immune system, infection, and inflammation

Coronary heart disease shows a winter peak and summer trough in incidence and mortality. A substantial part of a general population experiences seasonal mood changes including winter depression. Many studies demonstrate that depression is associated with increased incidence, morbidity, and mortality of cardiovascular disease. Therefore, the author previously suggested that persons with high levels of seasonality may be at increased risk of developing or worsening of coronary heart disease in the winter. Some psychological factors promote the development of disorders of the cardiovascular system. The same psychological factors decrease immunity and promote infection. There is evidence that the infectious process is involved in the pathogenesis of coronary heart disease. Therefore, the author previously proposed that the development of infection and inflammation in the atherosclerotic plaque may be related to the psychological disorders that suppress the immune system. In this paper, the author suggests that winter depression-induced suppression of the immune system may contribute to the winter increase in incidence and mortality of cardiovascular disease.     

The role of vagal function in the risk for cardiovascular disease and mortality

Cardiovascular disease (CVD) is the leading cause of death and disability worldwide. The understanding of the risk factors for CVD may yield important insights into the prevention, etiology, course, and treatment of this major public health concern. We review the evidence for the role of vagal function in the risk for cardiovascular disease and mortality. Using a broad range of indicators of vagal function including resting heart rate, heart rate recovery, heart rate variability, and baroreflex sensitivity we show that decreased vagal function is associated with an increased risk for morbidity and mortality. These effects are independent of traditional risk factors. Moreover, we show that decreased vagal function is associated with both traditional and emerging risk factors as well as modifiable and non-modifiable risk factors. Most importantly, we provide evidence to support the notion that decreased vagal function precedes the development of a number of risk factors and that modification of risk profiles in the direction of lower risk is associated with increased vagal function. We close with a brief overview of the neural concomitants of vagal function and suggest that a model of neurovisceral integration may provide a unifying framework within which to investigate the impact of risk factors, including psychosocial factors, on cardiovascular disease.     

Tree nut allergies: Allergen homology,cross‐reactivity,and implications for therapy

Tree nut allergy is a potentially life‐threatening disease that is increasing in prevalence, now affecting 1% of the general population in the United States. While other food allergies often resolve spontaneously, tree nut allergies are outgrown in less than 10% of cases. Due to the likelihood of cross‐sensitization to multiple tree nut allergens, the current treatment guideline is strict avoidance of all nuts once one tree nut allergy has been diagnosed. For example, walnut and pecan are highly cross‐reactive, along with cashew and pistachio, but the extent of clinical, IgE‐mediated cross‐reactivity among other tree nuts remains unclear, therefore making avoidance of all tree nuts a safe approach. There have been recent advances in immunotherapy for food allergies. For instance, there are investigational immunotherapies for milk, egg and peanut allergies, specifically oral immunotherapy, sublingual immunotherapy and epicutaneous immunotherapy. However, there are no large randomized controlled clinical trials for tree nut allergies. Even though there has been less research into tree nut allergy immunotherapies, the evidence of T‐cell cross‐reactivity among tree nuts exists in animal models and in T cells from allergic patients indicates that immunotherapeutic interventions may be possible. Here, we review the literature regarding epidemiology, allergen homology and cross‐reactivity among tree nuts, and explore how current findings can be employed for effective therapy.     

Saturated fat consumption may not be the main cause of increased blood lipid levels

Consumption of foods rich in saturated fatty acids (SFA) has often been associated with elevated blood lipid levels and consequently with risk for chronic diseases, including coronary heart disease. However, epidemiological and interventional studies on this topic are contradictory. While some studies have established a positive link, other studies have failed to show a significant association between saturated fat consumption and blood lipid levels, and others have even found an inverse association. Moreover, studies using animal models have demonstrated that dietary saturated fats raise blood lipid (cholesterol and triglycerides) levels only when the diet is deficient in omega-3 polyunsaturated fatty acids (n-3PUFA). The n-3PUFA are known for their potential in the management of hyperlipidaemia for the prevention of coronary heart disease, as well as for their anti-arrhythmic, anti-aggregatory and anti-inflammatory potential. We believe that with an adequate consumption of n-3PUFA dietary saturated fat may not result in elevated blood lipid levels. Therefore, we critically evaluated the literature regarding saturated fat and blood lipid level, with an emphasis on the role of n-3PUFA on this relationship. Evidence from animal studies and few clinical trials lead to the hypothesis that there are beneficial or neutral effects of saturated fatty acids when combined with recommended levels of n-3PUFA in the diet. However, an intervention focusing on the background fat when the volunteers’ diet is supplemented with n-3PUFA is yet to be done. Proving the authenticity of this hypothesis would mean a substantial change in public health messages regarding saturated fats and their health effects; and also a change in the strategies related to prevention of chronic cardiac and artery diseases.     

Real-world tree nut consumption in peanut-allergic individuals

BackgroundIndividuals with peanut allergy often avoid tree nuts, yet true rates of tree nut allergy in peanut-allergic individuals are as low as 7%.ObjectiveTo examine tree nut sensitization patterns in peanut-allergic individuals, patient and family choice regarding tree nut consumption, and factors that influence consumption of tree nuts.MethodsAll patients presenting for peanut allergy evaluation to an outpatient allergy office were included during a 4-month period. In addition to demographic information, sensitization to tree nuts and tree nut consumption were collected. Logistic regression was performed to generate odds ratios with 95% CIs in univariate and multivariate analyses for variables that predict tree nut consumption.ResultsA total of 258 individuals with peanut allergy were enrolled. Ninety-five (36.8%) consumed all tree nuts ad libitum, 63 (24.4%) consumed some but not all tree nuts, and 100 (38.8%) consumed no tree nuts. Of the 100 electively avoiding all tree nuts, the most commonly reported reason was fear of cross-contact (50%). Although there was no difference between rates of sensitization between individual tree nuts (P = .056), cashew and pistachio had higher serum specific IgE levels compared with other tree nuts (P < .001). The tree nut most commonly consumed by peanut-allergic individuals was almond (P < .001). Consumption of foods with precautionary labeling was the strongest predictor of tree nut consumption in peanut allergic individuals (P < .001)ConclusionOur data highlight the potential for safe introduction of tree nuts in peanut-allergic individuals and indicate that peanut-allergic individuals who consume foods with precautionary labeling are most likely to consume tree nuts.     

Tree nut allergens

Allergic reactions to tree nuts can be serious and life threatening. Considerable research has been conducted in recent years in an attempt to characterize those allergens that are most responsible for allergy sensitization and triggering. Both native and recombinant nut allergens have been identified and characterized and, for some, the IgE-reactive epitopes described. Some allergens, such as lipid transfer proteins, profilins, and members of the Bet v 1-related family, represent minor constituents in tree nuts. These allergens are frequently cross-reactive with other food and pollen homologues, and are considered panallergens. Others, such as legumins, vicilins, and 2S albumins, represent major seed storage protein constituents of the nuts. The allergenic tree nuts discussed in this review include those most commonly responsible for allergic reactions such as hazelnut, walnut, cashew, and almond as well as those less frequently associated with allergies including pecan, chestnut, Brazil nut, pine nut, macadamia nut, pistachio, coconut, Nangai nut, and acorn.     

Functional analysis of cross-reactive immunoglobulin E antibodies: peanut-specific immunoglobulin E sensitizes basophils to tree nut allergens

BACKGROUND: Peanut and tree nuts are a major cause of food-induced anaphylaxis with an appreciable mortality. Co-sensitization to peanuts and tree nuts is a common clinical observation and may be because of peanut-specific serum IgE antibodies that cross-react with tree nut allergens. It is, however, unclear whether these cross-reactive IgE antibodies are involved in effector-cell activation. OBJECTIVE: To determine if cross-reactivity of peanut-specific IgE antibodies with tree nuts can cause effector cell activation using an in vitro basophil activation assay. METHODS: Two peanut allergic subjects with positive specific IgE for peanut and tree nuts (as measured by CAP-FEIA) were studied. Basophil activation to peanut and tree nuts, as indicated by CD63 expression, was assessed by flow cytometry to confirm co-sensitization to peanut and tree nuts. Inhibition ELISA using sera from the subjects was performed to detect peanut-specific IgE antibodies that cross-reacted with tree nut proteins. To determine whether cross-reactive tree nut allergens can induce effector-cell activation, peanut-specific antibodies were affinity purified from the subject sera and used to resensitize non-peanut/tree nut allergic donor basophils stripped of surface IgE. Basophil activation was then measured following stimulation with peanut and tree nut extracts. RESULTS: The two peanut allergic subjects in this study showed positive basophil activation to the peanut and tree nut extracts. Inhibition ELISA demonstrated that pre-incubation of the peanut allergic subject sera with almond, Brazil nut and hazelnut extracts inhibited IgE binding to peanut extract. IgE-stripped basophils from non-peanut/tree nut allergic subjects resensitized with affinity-purified peanut-specific antibodies from the peanut allergic subject sera became activated following stimulation with peanut, almond and Brazil nut extracts, demonstrating biological activity of cross-reactive IgE antibodies. CONCLUSION: Peanut-specific IgE antibodies that cross-react with tree nut allergens can cause effector-cell activation and may contribute to the manifestation of tree nut allergy in peanut allergic subjects.     

Effects of heavy alcohol consumption on the cardiovascular system may be mediated in part by the influence of alcohol-induced depression on the immune system

The harmful effects of heavy alcohol use are well-documented and wide-ranging. Heavy drinking may cause or exacerbate cardiovascular disorders. The author suggests that effects of heavy alcohol consumption on the cardiovascular system may be mediated in part by the influence of alcohol-induced depression on the immune system. This hypothesis is based on the following data: (1) alcohol misuse may cause or exacerbate depression; (2) depressive disorders are associated with increased incidence, morbidity, and mortality of cardiovascular disorders; (3) the immune system may mediate effects of depressive disorders on the cardiovascular system. Further studies are needed to clarify the etiopathogenesis of alcohol-related disorders and develop new treatment modalities.     

beta-casein A1, ischaemic heart disease mortality, and other illnesses.

The risk factors identified with cardiovascular disease studied in the WHO MONICA project have been shown to have a limited relationship with the coronary heart disease mortality rates between centres, and in mirroring the historical rise and decline in deaths from the disease. Here we show that correlation of the calculated consumption of the milk protein, beta-casein A1 (excluding milk protein in cheese) against ischaemic heart disease (IHD) mortality has a r2 = 0.86. In the states of the former West Germany, where the breed composition of regional cattle herds has remained virtually constant since the 1950s, IHD mortality by state correlates with the estimated consumption of beta-casein A1. Information on other recognized dietary risk factors does not indicate any significant regional difference. Similarly, the populations of Toulouse in France and Belfast in Northern Ireland have almost identical collective 'traditional' risk factors for heart disease, yet the respective mortality rates vary more than threefold. People from Northern Ireland are estimated to consume 3.23 times more beta-casein A1, excluding cheese, than the French. The remarkable agreement between mortality and the consumption of this allele suggests that this factor is worthy of serious consideration as a potential source of cardiovascular disease when taken in conjunction with regional variations in the traditional risk factors. beta-casein A1 consumption also correlates strongly with type 1 diabetes incidence in 0-14-year-olds, suggesting that IHD and diabetes may share at least one causative risk factor.     

Late diagnosis of tree nut and sesame allergy in patients previously sensitized but tolerant to peanut.

BACKGROUND: Recent studies have indicated that tolerance to peanut can occur in patients with a history of peanut allergy. Tree nut and sesame allergies have been reported to occur at increased incidence in patients with peanut allergy. Although the coexistence may be simply due to a predisposition to food allergy in these individuals, cross-reactivity has been demonstrated between peanut and tree nuts and between peanut and sesame seed. OBJECTIVE: To describe 3 patients previously sensitized but tolerant to peanut who were subsequently diagnosed as having either tree nut or sesame allergy. METHODS: All the patients had a clinical history of peanut sensitivity and underwent follow-up peanut skin testing to commercial extracts using a bifurcated needle followed by a graded peanut challenge. One patient had a previous positive radioallergosorbent test reaction to sesame and underwent a graded sesame challenge. RESULTS: All the patients had negative peanut challenge results. Two patients subsequently had exposure to tree nuts at home and had systemic reactions and positive skin test reactions to the incriminated tree nut. One patient had a positive challenge reaction to sesame. CONCLUSION: Demonstration of tolerance to peanut may falsely reassure patients and physicians that patients no longer need to avoid tree nuts or sesame. Tree nut and sesame allergies can exist or develop in patients despite the development of tolerance to peanut.     

The impact of chocolate on cardiovascular health

Cardiovascular disease is the leading determinant of mortality and morbidity in women. Functional foods are attracting interest as potential regulators of the susceptibility to disease. Supported by epidemiological evidence, chocolate has emerged as a possible modulator of cardiovascular risk. Chocolate, or cocoa as the natural source, contains flavanols, a subclass of flavonoids. The latter years have witnessed an increasing number of experimental and clinical studies that suggest a protective effect of chocolate against atherogenesis. Oxidative stress, inflammation, and endothelial function define three biological mechanisms that have shown sensitivity to chocolate. Moreover, the consumption of chocolate has been involved in the protective modulation of blood pressure, the lipid profile, the activation of platelets, and the sensitivity to insulin. Dark chocolate seems more protective than milk or white chocolate. Despite this array of benefits, there is a lack of well designed clinical studies demonstrating cardiovascular benefit of chocolate. The high caloric content of chocolate, particularly of some less pure forms, imposes caution before recommending uncontrolled consumption.     

Specific immunoglobulin E to peanut, hazelnut and brazil nut in 731 patients: similar patterns found at all ages

BACKGROUND: Previous studies have reported reactions to an increasing range of nuts as patients with nut allergy grow older. Most patients with symptoms suggesting nut allergy have specific IgE to more than one nut. Furthermore, fatal reactions have followed eating nuts different from any causing the deceased's previous reactions. OBJECTIVE: To explore the pattern of specific IgE to three distantly related nuts in patients of all ages with nut allergy. METHODS: This study includes all patients referred to our laboratory for nut allergy testing from January 1994 to August 1998 who were tested for peanut, hazelnut and brazil nut, and had specific IgE to at least one of these nuts. All tests were performed using the Pharmacia Unicap system. RESULTS: Seven hundred and thirty-one patients (age 7 months to 65 years, median 6.6 years) had specific IgE >0.35 kU(A)/L to at least one of these three nuts: 282 had IgE to one nut, 130 to two nuts, and 319 to all three nuts. When analysed by gender and age quartile, very similar patterns were found in all subgroups though significant age trends and age interactions were found for IgE to individual nuts and combinations of nuts. CONCLUSIONS: The probability of a patient with nut allergy having specific IgE to a particular combination of peanut, hazelnut and brazil nut is similar, whatever their age or sex. The apparent increase in multiple nut reactivity with increasing age may therefore be due to exposure of previously unchallenged sensitivity. The frequency of multiple-nut specificity is sufficiently high that patients should always be tested for allergy to a range on nuts if they have a history of reacting to any nut.     

Omega-3 fatty acids and brain resistance to ageing and stress: Body of evidence and possible mechanisms

The increasing life expectancy in the populations of rich countries raises the pressing question of how the elderly can maintain their cognitive function. Cognitive decline is characterised by the loss of short-term memory due to a progressive impairment of the underlying brain cell processes. Age-related brain damage has many causes, some of which may be influenced by diet. An optimal diet may therefore be a practical way of delaying the onset of age-related cognitive decline. Nutritional investigations indicate that the ω-3 poyunsaturated fatty acid (PUFA) content of western diets is too low to provide the brain with an optimal supply of docosahexaenoic acid (DHA), the main ω-3 PUFA in cell membranes. Insufficient brain DHA has been associated with memory impairment, emotional disturbances and altered brain processes in rodents. Human studies suggest that an adequate dietary intake of ω-3 PUFA can slow the age-related cognitive decline and may also protect against the risk of senile dementia. However, despite the many studies in this domain, the beneficial impact of ω-3 PUFA on brain function has only recently been linked to specific mechanisms.This review examines the hypothesis that an optimal brain DHA status, conferred by an adequate ω-3 PUFA intake, limits age-related brain damage by optimizing endogenous brain repair mechanisms. Our analysis of the abundant literature indicates that an adequate amount of DHA in the brain may limit the impact of stress, an important age-aggravating factor, and influences the neuronal and astroglial functions that govern and protect synaptic transmission. This transmission, particularly glutamatergic neurotransmission in the hippocampus, underlies memory formation. The brain DHA status also influences neurogenesis, nested in the hippocampus, which helps maintain cognitive function throughout life.Although there are still gaps in our knowledge of the way ω-3 PUFA act, the mechanistic studies reviewed here indicate that ω-3 PUFA may be a promising tool for preventing age-related brain deterioration.     

n-3 PUFAs-From dietary supplements to medicines.

Although there has been a great progress in the prevention of cardiovascular diseases, the mortality of patients with acute myocardial infarction (AMI) still remains high. One of the most important underlying causes explaining this phenomenon is the sudden cardiac death. Nearly half of all cardiovascular deaths in the USA each year is attributed to this unpredictable and unexpected complication of AMI. Hence, there is an urgent medical need for a targeted therapy to reduce the incidence of sudden cardiac death. Since 1980 there have been several epidemiological and other studies concerning the benefits of n-3 polyunsaturated fatty acids (n-3 PUFAs) in cardiovascular health and prevention. Results from one of the largest studies, GISSI Prevenzione Trial show that adding the n-3 PUFAs to standard therapy of patients who survived AMI reduces sudden cardiac death (44% risk reduction, p=0.0006). In addition, significant decline in all-cause cardiovascular mortality (21% risk reduction, p=0.0064) further emphasizes the role of n-3 PUFA in cardiovascular prevention. To date, beneficial effects of n-3 PUFA are attributed to their antiarrhythmic, lipid lowering, antithrombotic and anti-inflammatory properties. To conclude, EPA and DHA improve the prognosis of cardiovascular patients in the secondary prevention of sudden cardiac death without any documented side effects.     

Dietary management of peanut and tree nut allergy: what exactly should patients avoid?

Peanut and tree nut allergies are the commonest cause of life‐threatening food‐allergic reactions and significantly affect quality of life in children and their families. Dietary nut avoidance and provision of emergency medication is currently the mainstay of treatment. Nut avoidance has consequences on both quality of life and nutrition. We review the terminology that may cause confusion and lead to unnecessary dietary restrictions. In peanut or tree nut‐allergic children, introduction of specific nuts to which the child is not allergic may improve quality of life and should be considered in patients with multiple foods allergies, vegan or ethnic‐specific diets, in whom nuts are an important source of protein. Nut‐allergic consumers do not just need to avoid foods containing nuts as an ingredient, but also contend with pre‐packed foods which frequently have precautionary allergen labelling (PAL) referring to possible nut contamination. Although the published rate of peanut contamination in ‘snack’ foods with PAL (see Box  1 ) ranges from 0.9–32.4%, peanut contamination in non‐snack items with PAL is far less common. We propose that in some peanut‐allergic patients (depending on history of reactivity to trace levels of peanut, reaction severity, other medical conditions, willingness to always carry adrenaline, etc.), consideration may be given to allow the consumption of non‐snack foods containing PAL following discussion with the patient's (and their family's) specialist. More work is needed to provide consumers with clearer information on the risk of potential nut contamination in pre‐packed food. We also draw attention to the change in legislation in December 2014 that require mandatory disclosure of allergens in non‐pre‐packed foods.