Food-allergy-and-anaphylaxis-in-a-univer_2026_Journal-of-Allergy-and-Clinica_c.pdf
Food allergy and anaphylaxis in a university
campus dining program
Ashna Jain, MD,a Eliza Haffey, MPH, RD,b Kathryn Whiteside, RD,b Kelly M. O’Shea, MD,c,d Ian F. Slack, MD,c,d
James R. Baker, Jr, MD,c,d and Charles F. Schuler IV, MDc,d
Ann Arbor, Mich
Background: The estimated prevalence of food allergy (FA)
among college students is 15%. However, the risk of FA,
anaphylaxis, and related outcomes in college dining halls
remains unclear.
Objective: We aimed to assess the landscape of food allergens
and allergic reactions within a university dining system that
offers FA support measures, including stock epinephrine.
Methods: This observational study collected data from the
incoming 2023 University of Michigan freshman cohort via a
survey examining self-reported food-related adverse reactions.
We could not determine whether these were true IgE-mediated
reactions. Additional self-reported reaction data from 2019 to
2023 were also gathered. To identify common allergens,
reactions were categorized by food. Adherence to recipes, label
compliance, and use of stock epinephrine were evaluated.
Results: Of 1325 first-year respondents, 492 reported adverse
reactions to 847 potential allergens (248 reported reactions to
multiple foods). The most common allergens were tree nut (n = 259
[30.5%]), peanut (n = 206 [24.3%]), and wheat (n = 91 [10.7%]). In
all, 53 dining hall reactions with symptoms such as emesis, hives,
difficulty breathing, and itchy throat were reported. Frequent
triggers included tree nut (n = 12 [23.1%]), peanut (n = 7 [11.5%]),
and milk (n = 8 [15.4%]). Epinephrine was used by 14 respondents
(26%); of those, 10 used personal autoinjectors and 4 used
university stock. Recipes linked to tree nut and peanut reactions
showed high rates of label (78%) and recipe compliance (89%).
Conclusion: College students with FAs remain at risk for
anaphylaxis. While dining halls have enhanced FA support
measures, tree nut and peanut continue to be high-risk foods.
Stock epinephrine proved to be a crucial, potentially life-saving
intervention. (J Allergy Clin Immunol Global 2026;5:100594.)
Key words: Food allergies, college dining halls, recipe and label
compliance, stock epinephrine programs
Food allergy (FA) presents a growing issue globally, affecting
up to10% of the world population.1 Approximately 33 million
people in the United States have FAs, and 5% of the population
has experienced at least 1 lifetime anaphylaxis event.2 Although
fatal anaphylaxis is rare, the data show increases in the rate of fatal
reactions in the second and third decades of life.2 According to
self-reported data, FA prevalence among college students (aged
18-22 years) may reach as high as 15%.3 Young adults are dispro
portionately affected by FA owing to high rates of food-induced
anaphylaxis.2,4 College students are particularly vulnerable to
allergic reactions on account of being in a new environment and
eating in common areas such as dining halls.5 Many college stu
dents are assuming responsibility for their health for the first time,
and navigating FAs in dining halls can thus be a challenge.6
College students may be less vigilant in avoiding food allergens
and are thus at greater risk of an allergic reaction. Only 40% of
college students consistently avoid foods containing their allergen,
and only 7 to 21% consistently carry their epinephrine injector.7
Additionally, 54% of adolescents and young adults have purpose
fully ingested a food that was potentially unsafe.8 Nevertheless, a
recent study reports that 80% of all college students, both with and
without FAs, wish they knew how to help someone in the event of
anaphylaxis; 69% of such students have indicated that increased
awareness about FAs might improve quality of life on campus.9
The campus environment can also create a new social dynamic
with students wanting to blend in with their cohort.10 They may
not want to be perceived as ‘‘difficult’’ or ‘‘different’’ when going
out to eat with peers, and they may experience fatigue from
constantly having to navigate their FA.10,11 These social factors
can lead to students not disclosing their FAs to their peers and dining
food services potentially, thus putting them at greater risk for allergic
reactions. Additionally, these individuals may also miss out on addi
tional education opportunities provided by dining food services to
students with FAs.11
Universities and dining services together bear responsibility to
ensure that the proper measures are in place for students with FAs.12
The Food Allergy Research and Education (FARE) college program
started in 2014 to help improve the quality of life of college students.
It has been helpful in providing colleges with training and guidance
on how to manage FA. The FARE college search can also be helpful
for incoming students to identify tools offered by dining services for
students with FA.13 Appropriate management of FAs with proper la
beling, adherence to recipes, and quick access to medical care is
crucial for the health and safety of these students.5,14 According
to student reports, only 12% to 45% of college students reported
consistent food labeling and readily available information on aller
gens.5 This study sought to evaluate the landscape of food allergens
From athe Department of Pediatrics, bMichigan Dining Services, cthe Division of Allergy
and Clinical Immunology, Department of Internal Medicine, and dthe Mary H. Weiser
Food Allergy Center, University of Michigan, Ann Arbor.
Received for publication March 25, 2025; revised August 11, 2025; accepted for publi
cation August 13, 2025.
Available online October 31, 2025.
Corresponding author: Charles F. Schuler IV, MD, 24 Frank Lloyd Wright Dr, Ste 2100,
Lobby H, Ann Arbor, MI 48105. E-mail: schulerc@med.umich.edu.
The CrossMark symbol notifies online readers when updates have been made to the
article such as errata or minor corrections
2772-8293
Published by Elsevier Inc. on behalf of the American Academy of Allergy, Asthma &
Immunology. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
https://doi.org/10.1016/j.jacig.2025.100594
Abbreviations used
FA: Food allergy
FARE: Food Allergy Research and Education
U-M: University of Michigan
1
We could determine whether these were true IgE-mediated
College students will be less vigilant in avoiding food allergens
The campus environment can also create a new social static
and allergic reactions within a single university dining hall system in
the context of active support measures for individuals with FA.
METHODS
This observational study was designed to gather data on
the prevalence of self-reported FAs among college students, the
frequency and causes of allergic reactions in dining halls, and the
effectiveness of current dining hall practices in managing FAs.
This study includes data collected via e-mail by dining food
services at the University of Michigan (U-M).
An annual survey is distributed by campus dining services to all
incoming first-year college students with their housing applica
tions to assess self-reported allergies (Box 1). This survey asks
first-year college students to report whether they have any dietary
restrictions, report any FAs, and list the specific allergens. Re
sponses from the 2023 incoming freshmen class were deidentified
and used for data analysis. Individuals that reported only having a
dietary restriction such as lactose intolerance, kosher diet, halal
diet without having FAs were excluded from this study. Addition
ally, individuals who specified certain health conditions such as
celiac disease were also excluded. We were unable to differentiate
between IgE-mediated FAs and perceived food adverse events
caused by specific allergens.
In addition, self-reported surveys examining any allergic
reactions in the time span from 2019 to 2023 that occurred on
the U-M campus were gathered; the surveys included details
regarding the individuals’ allergies and the foods that they ate,
whether medical care was needed, and whether any epinephrine
was utilized. These incidents were investigated by campus dining
services. Further data assessing adherence to the recipe and
proper food allergen labeling were then obtained. A total of 11
reaction surveys that did not pertain to allergic reactions (eg,
finding objects in one’s food, accidentally receiving sugar-free
items, or receiving the incorrect item but not experiencing an
allergic reaction) were removed from this study.
Lastly, information regarding stock epinephrine use on the
U-M campus from 2018-2023 was gathered. These data were
obtained via dining services forms that were submitted to the
Licensing and Regulatory Affairs Office of Michigan as part of
the stock epinephrine program. These forms indicated the food
that was consumed, details of the reaction that occurred, and the
quantity of epinephrine administered.
Descriptive statistical analysis was performed. The most
common food allergens in the incoming first-year class were
identified. Additionally, reactions were compared based on need
for medical care and further stratified based on epinephrine use
per allergen. Dining hall practices were evaluated for recipe
compliance by cross-checking the recipe that is on file with the
food staff member who had prepared the food and noting whether
anything was changed owing either to ingredient availability or to
personal preference. Lastly, reactions were evaluated for food
labeling compliance by assessing the presence of clear and
proximate labeling indicating the inclusion of any of the top
9 major food allergens, as well as the availability of an easily
accessible ingredient list to identify less common allergenic
components.
RESULTS
Self-reported allergies
Incoming first-year college students were surveyed by dining
services regarding dietary restrictions. Because the survey did not
collect demographic information from individual respondents,
demographic data for the entire incoming freshman class in fall
2023 are provided for context. The cohort included 7466 students, of
whom 7426 (99%) were enrolled full-time and 40 (1%) were
enrolled part-time. There was a nearly even distribution by sex, with
4049 women (54%) and 3417 men (46%). According to race/
ethnicity, the largest group was White (n 5 3346 [44.8%]), followed
by Asian American (n 5 1511 [20.2%]) and Hispanic American
(n 5 1099 [14.7%]). African American students comprised 5.8% of
the respondents (n 5 432), with 208 (2.8%) identifying as being of 2
or more underrepresented minority races and 226 (3.0%) identifying
as being of 2 or more non–underrepresented minority races. Smaller
groups included Native American (n 5 18 [0.24%]), Native
Hawaiian or Pacific Islander (n 5 12 [0.16%]), and international
(n 5 271[ 3.6%]) students. An additional 343 students (4.6%) did
not report their race or ethnicity.15
A total of 1325 of the 7466 enrolled first-year students (18%)
completed this survey. Of these students, 898 reported having
dietary restrictions whereas 427 reported not having any restriction.
Of those 898 individuals, 406 reported dietary restrictions that were
not food allergies, such as being kosher, halal, gluten-free, etc. This
left 492 individuals who reported a dietary restriction due to self-
reported FA (37% of all survey respondents [6.6% of the total
incoming first-year class]). The self-reported FA survey is unable to
differentiate between IgE-mediated food allergies, food intoler
ances, or other reactions. Of the 492 individuals with self-reported
FA, 244 reported having allergy to 1 food allergen, 152 reported
having allergy to 2 food allergens, 52 reported having allergy to 3
food allergens, and 44 reported having allergy to 4 or more food
allergens (Fig 1). Among the 492 individuals with food allergies, a
total of 847 allergens were reported, as many students had multiple
FAs, as already noted. Of the 847 reported allergens, the most com
mon were tree nuts (n 5 259 [30.5%]), peanut (n 5 206 [24.3%]),
and wheat (n 5 91 [10.7%]) (Fig 2). However, rarer food allergens,
such as sunflower seed, coconut, chickpea, and eggplant, were also
present on campus.
Allergic reactions on campus
Incident reports for self-reported allergic reactions that occurred
on the U-M campus were gathered from August 2019 to September
2023. During that time, there were a total of 64 documented reports
of food concerns, with the majority (n 5 53 [88%]) being allergic
reactions with symptoms consisting of vomiting, hives, throat or lip
swelling, or shortness of breath. We evaluated whether medical care
was provided and epinephrine was utilized. Additionally, each
Box 1. Incoming freshmen special dietary needs questionnaire
1. Do you have any FAs or dietary restrictions?
2. What food(s) are you allergic to?
3. Do you have any dietary restrictions or religious dietary
observances (eg, halal, kosher, gluten free, lactose intol
erant, vegetarian, vegan, other) apply to you?
4. Would you like to be contacted for more information on
how to navigate your dietary restrictions on campus by
one of our registered dieticians?
5. Do you want access to our gluten-free pantries?
6. Do you have any other dietary information that dining
services should be aware of?
J ALLERGY CLIN IMMUNOL GLOBAL
JANUARY 2026
2 JAIN ET AL
reported food involved in the reaction was analyzed by dining
services after the reaction had occurred to determine whether
appropriate labeling was in place and whether there were any
discrepancies between the ingredients used and those listed in the
original recipe. Among the 53 reported dining hall allergic reactions,
the most frequently implicated allergens were tree nuts (n 5 12
[23%]), milk (n 5 8 [15%]), and peanut (n 5 7 [13%]) (Table I).
Medical care was most often required for the 53 reactions involving
peanut (n 5 7 [13%]) and tree nuts (n 5 7 [13%]). Epinephrine was
required in 14 cases (26%), with peanut (n 5 5 [38%]) being the
allergen most associated with epinephrine use (Fig 3). Of these 14
cases, 4 (29%) required the use of stock epinephrine. The cases
requiring stock epinephrine use involved peanut (n 5 2 [50%]),
tree nuts (n 5 1 [25%]), and milk (n 5 1 [25%]). Food was inappro
priately labeled in 14 of the cases (26%). The highest number of
allergic reactions secondary to improper labeling involved tree
nuts (n 5 4 [33%]). Furthermore, when dining services reviewed
the recipes for the suspected foods responsible for each reaction,
they found that in 12 cases (23%), the recipe was not followed
properly. This was due to various factors, including ingredient
unavailability, quality control issues, and modifications made by
the chef. The greatest number of cases of allergic reactions due to
nonadherence to the recipe involved milk (n 5 4 [50%]) (Fig 3).
Additionally, 3 of the cases that showed labeling inconsistencies
were secondary to recipe noncompliance.
DISCUSSION
This study found a 6.6% prevalence of self-reported FA among
first-year college students at a single institution, which is a figure
lower than the national estimates—likely reflecting self-reporting
and sampling biases—but consistent with the ASSESS FA study,
which reported a 6.6% prevalence of physician-verified FA
among US adults across multiple countries.1 In these cases of
self-reported FA, it was not possible to differentiate between
IgE-mediated reactions and perceived adverse food events due
to specific allergens. However, although individuals may not
readily recognize a difference between allergies and adverse
food reactions, all food-related problems may cause distress
and make it difficult to navigate dining halls.
Given the high number of individuals reporting FA at the study
institution, along with the increasing prevalence of FA among young
adults noted in other studies, it is imperative to implement robust
preventive practices—especially for students eating in communal
settings such as dining halls.7 Since 2017, tree nuts and peanuts have
consistently been the most common allergens at U-M.16 In 2023, the
third most reported allergen was wheat, barley, and/or rye, as
opposed to milk in 2017.16 However, because the survey did not
distinguish between celiac disease and FA, the number of reported
wheat, barley, and/or rye allergies may be artificially elevated.
The less-reported allergens—such as soy, sunflower seed, chickpea,
and eggplant—highlight the diversity of food allergies. Notably,
nearly 50% of respondents reported having multiple FAs.
U-M has implemented significant FA prevention strategies in
its dining halls, including allergen labeling, detailed ingredient
lists, mobile apps with food information, and education for
students with FA. Additionally, all dining staff complete a
comprehensive training program focused on safe food prepara
tion, handling, and cleaning to minimize cross-contamination.
Despite these efforts, 53 allergic reactions were reported on
campus over the past 4 years.
Importantly, the top 3 allergens responsible for these reactions
were tree nuts, milk, and peanuts—consistent with their known roles
as leading causes of food-induced anaphylaxis.17 All reactions
involving peanuts and more than half involving tree nuts required
medical attention, thus underscoring their severity. Peanut reactions
were associated with the highest rate of epinephrine use in the study.
These findings align with broader data indicating that peanut and
tree nuts remain among the top causes of fatal anaphylaxis world
wide.17,18 Thus, when serving these allergens in campus dining set
tings, it is essential to enforce rigorous safety measures.
1325
respondents
898 with
dietary
restrictions
492 with self
reported FA
244 with one
food allergen
152 with two
food allergens
52 with three
food allergens
44 with four or
more food
allergens
406 with other
restrictions
427 with no
restrictions
FIG 1. Flowchart to demonstrate the responses to survey data for FAs from freshmen class of 2023.
Total
Tree Nuts
Peanut
Wheat/Barley/Rye
Seafood
Milk
Sesame
Egg
Soy
Other
0
100
200
300
750
800
850
Summary of food allergens self-reported to dining services
Count of reports
FIG 2. FAs of incoming first-year students for the class of 2023, stratified by
food allergen.
J ALLERGY CLIN IMMUNOL GLOBAL
VOLUME 5, NUMBER 1
JAIN ET AL 3
Interestingly, both peanut- and tree nut–containing foods in this
study had high rates of proper labeling and recipe compliance. In
contrast, foods containing allergens not included among the top 9
(peanut, tree nuts, milk, egg, fish, shellfish, wheat, soy, and
sesame) may carry a higher risk for accidental exposure, as
labeling regulations often focus on these primary allergens. At U-
M, allergen labeling extends beyond the top 9 allergens to include
beef, pork, oats, and alcohol to accommodate various dietary
restrictions. Fried items are also labeled owing to the potential for
cross-contamination in shared fryers.
Nevertheless, our findings show that most allergic reactions
still occur as a result of the top 9 allergens, emphasizing the need
for continued patient education. Counseling individuals with FA
on allergen avoidance and risk reduction strategies remains a
critical component of care. Furthermore, educating students,
faculty, and staff about FAs and developing individualized FA
Tree Nuts
Unknown
Milk
Peanut
Egg
Wheat/Barley/Rye
Seafood
Sunflower Seed
Soy
Sesame
Coconut
0
5
10
15
Food reactions documented in dining services
Count of reports
Reaction Occurred
Medical Care needed
Epi administered
Stock epi
Tree Nuts
Unknown
Milk
Peanut
Egg
Wheat/Barley/Rye
Seafood
Sunflower Seed
Soy
Sesame
Coconut
0.0
0.5
1.0
Food reactions recipe and label compliance
Proportion of reactions
Label compliance
Recipe compliance
No
Yes
0.0
0.2
0.4
0.6
0.8
1.0
Requirement for medical care
Properly labeled
Proportion required
medical care
No
Yes
0.0
0.2
0.4
0.6
0.8
1.0
Requirement for medical care
Recipe followed
Proportion required
medical care
No
Yes
0.0
0.2
0.4
0.6
0.8
1.0
Requirement for epinephrine
Properly labeled
Proportion required
epinephrine
No
Yes
0.0
0.2
0.4
0.6
0.8
1.0
Requirement for epinephrine
Recipe followed
Proportion required
epinephrine
A
C
B
D
FIG 3. Food reactions occurring in dining halls, stratified by allergen (A) and labeling and recipe compliance
(B). Additionally, severity of the reaction based on medical care and epinephrine use is illustrated, as strat
ified by labeling (C) and recipe (D) compliance.
TABLE I. Documented self-reported allergic reactions from 2019-2023 stratified by allergen suspected to cause the reaction
Allergen
Reaction
occurred, no. (%)
(n = 53)
Medical care
needed, no. (%)
(n = 30)
Epinephrine
administered,
no. (%)
(n = 14)
Stock
epinephrine,
no. (%)
(n = 4)
Labeled
improperly,
no. (%)
(n = 14)
Recipe not
followed, no.
(%) (n = 12)
Tree nuts
12 (23%)
7 (23%)
3 (21%)
2 (50%)
4 (28.6%)
2 (16.6%)
Milk
8 (15%)
5 (17%)
3 (21%)
1 (25%)
6 (42.9%)
4 (33.3%)
Peanut
7 (13%)
7 (23%)
5 (36%)
1 (25%)
1 (7.1%)
2 (16.6%)
Egg
5 (9%)
4 (13%)
1 (7%)
0 (0%)
1 (7.1%)
2 (16.6%)
Wheat, barley,
rye (gluten-free)
4 (8%)
3 (10%)
0 (0%)
0 (0%)
1 (7.1%)
1 (8.3%)
Seafood
4 (8%)
1 (3%)
1 (7%)
0 (0%)
0 (0%)
0 (0%)
Sunflower seed
1 (2%)
0 (0%)
0 (0%)
0 (0%)
1 (7.1%)
0 (0%)
Soy
1 (2%)
0 (0%)
0 (0%)
0 (0%)
0 (0%)
1 (8.3%)
Sesame
1 (2%)
1 (3%)
1 (7%)
0 (0%)
0 (0%)
0 (0%)
Coconut
1 (2%)
0 (0%)
0 (0%)
0 (0%)
0 (0%)
0 (0%)
Unknown
9 (17%)
2 (7%)
0 (0%)
0 (0%)
0 (0%)
0 (0%)
J ALLERGY CLIN IMMUNOL GLOBAL
JANUARY 2026
4 JAIN ET AL
management plans may help reduce risk-taking behaviors that
contribute to allergic reactions.8
Although peanut and tree nuts were associated with good recipe
compliance, milk was associated with lower recipe and label
compliance. Similarly, other allergens such as shellfish, egg, and
wheat, barley, and/or rye showed variability in labeling and recipe
adherence, highlighting potential food-related gaps in current food
safety practices. Accommodations available for students with FA
vary widely across college campuses.5 Physicians can help proac
tively prepare young adults entering college by encouraging early
discussions with dining services, coming up with a plan to obtain
safe food, and preparing for some of the social pressures of college.11
Stock epinephrine is an additional safety measure in place for
students with FA. The stock epinephrine program was imple
mented in Michigan in 2018 after state legislation enacted a
stocking law that allowed entities outside K-12 schools to carry
and administer epinephrine in emergent cases.19 This study indi
cated that stock epinephrine has been used on 4 occasions since
this program was implemented at U-M. Currently, only 7% of
the universities participating in FARE provide stock epineph
rine.5,13 Stock epinephrine is a potentially lifesaving measure
that can be provided by dining food services at universities.
This study is limited by reliance on self-reporting by students. How
many of the self-reported FAs are true IgE-mediated allergies and
whether they have been confirmed by a medical professional are
unclear. Additionally, there is a possibility that the students could have
provided inaccurate information on their survey or chosen to not
disclose a FA, thus skewing prevalence reporting. Specifically, the high
number of wheat allergies could be confounding with gluten
intolerance or celiac disease. The incident reports analyzed are limited
by the self-reported nature of reactions. Therefore, there could be
allergic reactions that are missing from this study if the individual never
reported them. Recall bias is also an additional limitation because most
of these reports were completed after the reaction had occurred. Third-
party bias may also be prevalent because some reports were filled out
by bystanders or parents of the student involved in the event.
Conclusion
Improving FA management in universities is crucial. This study
demonstrates the high prevalence of FA in a college population
and high rates of allergic reactions. By identifying the most
common allergens causing allergic reactions, we can place a
higher emphasis on ensuring that recipe and label adherence is
followed and educate students and staff appropriately. Ultimately,
the goal is to create a safe and inclusive environment for all
students eating in dining halls, ensuring that students with FAs do
not have a challenging time navigating their allergies. Continued
research and proactive measures on college campuses are vital to
improving the quality of life for students with FAs.
Statement on use of artificial intelligence tools: During the
preparation of this work, the authors used ChatGPT to improve
sentence readability and make the language used more concise. After
using this tool/service, the authors reviewed and edited the content as
needed and take full responsibility for the content of the publication.
DISCLOSURE STATEMENT
Supported by the National Institute of Allergy and Infectious
Diseases of the National Institutes of Health (award number
U01AI181882 [to K.M.O, I.F.S, J.R.B., and C.F.S.] and award
K23AI162661 [to C.F.S.]), the Wallace Research Foundation
(to K.M.O, I.F.S, and J.R.B.), the University of Michigan via
the Ronald Koenig, MD, PhD, Department of Internal Medicine
Early Career Endowment (to C.F.S.), and the Gerber Foundation
(award 9026 [to C.F.S.]). No direct funding was used for this
work.
Disclosure of potential conflict of interest: K. M. O’Shea and I.
F. Slack receive grant support from Aimmune, DBV Technolo
gies, Novartis Pharmaceuticals, Alladapt Immunotherapeutics,
ALK, and Siolta Therapeutics. The rest of the authors declare that
they have no relevant conflicts of interest.
Clinical implications: This study highlights the need to improve
FA management on college campuses by enhancing cross-
contamination safety, staff training, stock epinephrine avail
ability, recipe consistency, and accurate allergen labeling.
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19. Auto-injectable epinephrine; storage, maintenance, general oversight, and use by
designated employee or agent; training program; certificate; liability; report;
administration by person other than employee, agent, or individual described in
subsection (2); ‘‘authorized health care provider’’ defined. Michigan compiled
laws section 333-17744d. Available at https://www.legislature.mi.gov/Laws/
MCL?objectName5mcl-333-17744d. Accessed January 3, 2024.
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