BY MICHELLE BRUSIO, MSN, RN, CCM
There is often confusion between food allergies and food intolerances. Food allergies and food intolerances can share similar symptoms; however, they can also differ significantly in severity, cause, and overall body reaction. Food intolerances can cause discomfort, leaving one feeling miserable. However, a food allergy reaction is emergent and potentially life-threatening and may need epinephrine and a trip to the emergency room. Food intolerances are more common than food allergies, thank goodness.
Food Allergies
Thirty-three million people in the United States have a food allergy. There are nine major food allergens, including milk, eggs, fish, shellfish, nuts, peanuts, wheat, soybeans, and sesame. There are more allergens, but the nine major food allergens are also the most common. Your body’s immune system overreacts, producing antibodies of the Immunoglobulin E (IgE) type. These antibodies can then cause an anaphylactic reaction (shortness of breath, throat closure, lip and tongue swelling, hives, itchiness, and the feeling that something bad may happen). An allergic reaction can happen immediately after consuming an allergen. The key to preventing a reaction to food allergies is simply avoiding allergens.
Food Intolerances
According to the American Academy of Allergy, Asthma & Immunology (AAAAI), a food intolerance takes place in the digestive system, where one is unable to break down the food properly. This may be attributed to several factors, including enzyme deficiencies, sensitivity to food additives, or reactions to naturally occurring chemicals present in food. Examples of food intolerant foods are lactose, gluten, and fructose. People with food intolerances develop gas, diarrhea, headache, vomiting, fatigue, and agitation. These symptoms typically appear within hours to days after consuming a food item that causes intolerance. Food intolerances are not life-threatening.
Celiac Disease
Celiac disease is interesting because it is an autoimmune condition where gluten is the culprit in damaging your small intestines. Gluten is one of the proteins found in wheat, barley, rye, and more. Celiac disease can be harrowing and cause issues with nutrition and growth, and if left untreated, it can cause damage to other organ systems. Celiac disease may cause gastrointestinal problems, joint pain, and headaches.
Our Role as Case Managers
The most important role of a case manager when it comes to food allergies, food intolerances and celiac disease is to educate our patients and caregivers. Education on food allergies includes avoidance of the allergens, recognizing the signs and symptoms of an allergic reaction, and understanding when and how to administer epinephrine. Another challenge is that 40% of children have multiple food allergies, making mindfulness essential for identifying new allergens (Food Allergy Research & Education, 2025).
Another important aspect of education for food allergies, food intolerances, and celiac disease is understanding which foods you can and cannot eat, as well as knowing about suitable food substitutions. For example, going out to eat can be a challenge, but requesting a product guide with ingredient lists can be helpful in knowing what dishes to avoid or to ask for a gluten-free version. Educating restaurant staff can be lifesaving or save you from feeling miserable due to food intolerance. I have personally requested to speak with the chef at restaurants before when I did not feel my waiter was taking our allergy needs into account.
Case managers can also help individuals discuss loneliness and social isolation related to food allergies and intolerances. Seeing others eat foods they cannot have can be distressing. Anxiety is also prevalent in people with food allergies due to the fear of eating something that contains an allergen and then causing a life-threatening situation. Fear and anxiety are real in food intolerances and celiac disease due to headaches and gastrointestinal symptoms.
Social Determinants of Health
During the education of our patients, another topic is social determinants of health. Epinephrine, food substitutes, and multiple doctor appointments can be extremely expensive. Gluten-free products are 2-3 times more expensive than regular gluten-containing items. Most food pantries do not carry allergen-free items. Other social factors may include a lack of transportation, inadequate early introduction of food to children, a shortage of specialist care, such as allergists or gastrointestinal providers, and increased emergency room utilization resulting from a lack of education about food allergies or food intolerances.
Conclusion
It is essential to determine whether you have a food allergy or are food intolerant. Every 10 seconds, someone visits the emergency room due to a food allergy, and 64% of people with anaphylaxis do not receive epinephrine before arrival, increasing the risk of adverse outcomes (Food Allergy Research & Education, 2022). Food intolerances and celiac disease can have adverse effects on the gastrointestinal system. Proper diagnosis and follow-up with a provider, as well as appropriate education, can be a matter of life or death.
References
American Academy of Asthma, Allergy & Immunology, (2025, January 10). Food Intolerance versus Food Allergy. Food Intolerance Versus Food Allergy
Food Allergy Research & Education. (2025). Facts and Statistics. Facts and Statistics – FoodAllergy.org
Food Allergy Research & Education. (2022, December 12). Only half of adult food allergy patients surveyed report being prescribed epinephrine auto-injectors. Only Half of Adult Food Allergy Patients Surveyed Report Being Prescribed Epinephrine Auto-Injectors – FoodAllergy.org
Michelle Brusio, MSN, RN, CCM, has been an RN for 26 years and in case management for 20. She is currently the clinical manager for population health, care transformation organization and primary care at University of Maryland Upper Chesapeake Health. Michelle has experience in acute care, payer, primary care, and outpatient case management. Michelle serves on several local committees in Harford County, Maryland. Michelle also serves on several CMSA national committees. On a personal note, Michelle is a fierce allergy mom and advocate, and volunteers with her certified pet therapy dog, Gunnar Henderson.
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