Air Travel with Food Allergy Survey: From Anxiety to Crew Issues

Air travel causes widespread anxiety among passengers managing food allergies, according to a comprehensive new survey. Ninety-eight percent of 4,704 respondents reported some level of anxiety over air travel. Two-thirds of the survey group reported “a lot” of anxiety.

“I knew people were stressed when flying with food allergies, but 98 percent is surprising,” says Lianne Mandelbaum, who runs the nonprofit No Nut Traveler.

Mandelbaum partnered with researchers and physicians to launch the survey, designed by Northwestern University’s Center for Food Allergy & Asthma Research (CFAAR). In October and November 2022, patients and caregivers from across the globe answered the survey’s questions about food allergies and air travel. The data collected reveal perspectives about flying challenges, in-flight reactions, accommodations, and treatment by airline crews.

The survey sample is a robust representation of the broad food allergy community, including adult patients, parents of young children and teens, and partners, of food-allergic adults, says Christopher Warren, PhD, director of population health research for CFAAR. Nearly 5,000 participants is a large number of respondents for a survey. Also of note: 99 percent reported physician-diagnosed food allergies.

Warren will be the lead author of a study from these findings. He also presented the survey results at the American Academy of Allergy Asthma & Immunology (AAAAI) allergists’ conference in San Antonio in late February.

In a key section, the survey asked participants which factors influence their flight choices. The results show that an airline’s food allergy management policies, previous experiences, and recommendations from other passengers carry more weight than non-food allergy factors such as cost and location, Warren says.

The survey asked: “When treated well, are you more likely to choose this airline due to your positive experiences, instead of choosing the airline based on other factors?” Almost 74 percent said “yes, a lot more likely.”

Air Travel Anxiety and Policy Difference

“Having a good food allergy policy is driving decision-making when choosing a flight,” says Mandelbaum. She says the aviation industry should take note of the economic impact. “When there’s a solid food allergy policy in place, we become loyal, repeat customers.”

Airline policies and accommodations are shown to be key to decreasing the high anxiety in flying with food allergies. About two-thirds of the respondents who reported air travel anxiety said their stress would lessen with better policies and accommodations.

So, while the level of anxiety is distressing, knowing there are ways to help through policy and accommodations is hopeful. “That’s an achievable goal,” Mandelbaum says.

The accommodations that respondents appreciate most include:

Opportunity to pre-board.
Availability of allergy-friendly snacks.
PA announcements about food allergies on the flight.
Establishing a buffer zone anonymously (to not single out the food-allergic passenger).

The ability to pre-board to clean the passenger’s seating area received the highest percentage with 30 percent of respondents naming that accommodation as the most appreciated.

This finding doesn’t surprise Mandelbaum. Pre-boarding for food allergies allows parents and patients to wipe down a seating area that may have allergen residue from previous passengers. This is a vital step food-allergic passengers can take to mitigate the risk of an allergic reaction, she says.

“There are legitimate reasons to ask for these accommodations,” Mandelbaum says.

Air Travel: Communication and Treatment

The need for coherent management and communication about the plan to keep food-allergic passengers safe is apparent, Warren says.

For example, the air travel survey showed:

47 percent report being assured of accommodation that was provided.
36 percent report being assured of accommodation that was then not provided.
13.8 percent say they received conflicting messages from flight crew.
11.8 percent say they were asked to leave a flight or denied boarding.
35.6 percent report airline staff treating them in an unprofessional or insensitive manner because of food allergy. Of those respondents, 76 percent said the experience impacted how they fly.

While 4.1 percent reported being asked for a “fit-to-fly” note, Mandelbaum recommends that passengers with food allergies carry a doctor’s note outlining the need to carry medication regardless of the airline policy.

The data show inconsistency in how food-allergic passengers are treated, even when flying on the same airline, Mandelbaum says. She attributes that to crew not being educated on allergies, a lack of consistent policies, no consistency in applying policies. As well, there are seldom repercussions for failing to accommodate food-allergic passengers.

“There’s such an unfair burden on the passengers with food allergies,” she says.

In-Flight Reactions: 40% Not Reporting

Survey respondents (8.5 percent of the sample) reported 400 in-flight reactions, mostly to peanut or tree nuts. They mentioned symptoms involving skin, respiratory, gastrointestinal and cardiovascular systems. Yet, most patients used antihistamines (61 percent) for treatment, while only 15 percent administered epinephrine. Another 15 percent used albuterol reliever inhalers, according to survey results. The remainder used other medications.

Personal epinephrine auto-injectors were used for most of the 60 reactions treated with epinephrine. Warren says only three cases involved airline-provided epinephrine (two vials, one auto-injector).

A concerning trend is that about 40 percent of passengers did not report their in-flight reactions to the crew or airline. “I was a bit surprised about how relatively infrequent the reactions were reported to the airlines during or after the flight,” Warren says.

To Mandelbaum, this shows the need for work in educating airline staff about food allergies, and passengers about their rights. Passengers should not be afraid to speak up for fear of getting in trouble, or being treated with insensitivity, she says.

One-third of passengers also say they are deliberately not reporting their allergies when they fly. Mandelbaum sees that finding as disturbing – and dangerous. If the passenger does have a reaction, she notes that the flight crew could misinterpret symptoms, and no one would know where the passenger’s medication is located.

“There is a possibility that there will be a tragic outcome,” she says.

Use of Airline Survey Data

The effort in the air travel survey to collect the perspectives of passengers managing food allergies provides needed data. The researchers’ intent is to help foster understanding about how best to manage food allergies during air travel.

“This is a topic that is really close to the hearts of a lot of folks dealing with traveling with food allergies,” Warren says. While the survey answers represent various types of travelers, most respondents flew for personal trips.

The survey’s concrete information about various aspects of flying with food allergies show that this area deserves attention and further study, Mandelbaum says. Warren hopes the data will encourage more research and eventually guide policy that makes life easier for travel with food allergies.

“There is a need to listen to patients and advocates of folks with food allergies about how to manage it,” he says. “Clearly food allergy is impacting how people travel.”