Tree Nut Allergy Diet Guide: What You Need to Know

Learn how to choose safe foods in stores and restaurants

bowl of nuts
GARO/PHANIE / Getty Images

Tree nuts are a common food allergy: in the United States, about 0.5% of the population—or about one in every 200 people—is allergic to tree nuts. Tree nuts frequently cause strong allergic reactions and may cause anaphylaxis, which is a potentially life-threatening allergic reaction.

The most common tree nuts include macadamia nuts, brazil nuts, cashews, almonds, walnuts, pecans, pistachios, chestnuts, hazelnuts (filberts), and pine nuts (pignoli or pinon).

Less common tree nuts include beechnuts, butternuts, chinquapins, gingko, hickory nuts, lychee nuts, pili nuts and shea nuts.

The majority of individuals with a tree nut allergy will have it for their lifetime. However, recent research indicates about 9% of children with tree nut allergy will outgrow that allergy. For this reason, physicians recommend that children with allergies to tree nuts be reevaluated periodically by a ​board certified allergist to see if they're in the group that outgrows the allergy. Children who are allergic to multiple types of tree nuts (more than one or two) are less likely to outgrow their allergy than children who are allergic to just one type of tree nut.

Allergies to More than One Nut

People can be allergic to one type of tree nut, to some tree nuts, or to many tree nuts but not to other types of tree nuts. That's because some tree nuts contain similar proteins—for example, almonds and hazelnuts contain similar proteins, as do walnuts and pecans, and pistachios and cashews.

Because of these protein similarities, it is common for an individual to have an allergy to both nuts. For instance, if you are allergic to cashew, you have a greater risk of being allergic to pistachios, as well.

However, most people with tree nut allergy are not allergic to all tree nuts. The decision to avoid all tree nuts when there is an allergy to one or more tree nuts is a personal one, and one you should discuss with your doctor.

In food production, the risk of cross-contact with multiple tree nuts is higher, which has led many health professionals to recommend avoidance of all tree nuts. 

Allergy to Both Tree Nuts and Peanuts

Peanuts are legumes and are biologically unrelated to tree nuts. Tree nut allergy and peanut allergy are two different types of allergies. Still, while people allergic to tree nuts are not necessarily allergic to peanuts, it's also possible be allergic to both.

You should be aware that tree nuts and peanuts are often found together in processed foods and nut mixtures. If you are diagnosed with a tree nut allergy, your allergist will advise you whether to avoid peanuts, as well.

Symptoms Associated with Tree Nut Allergy

Symptoms associated with a tree nut allergy include:

People with tree nut allergy should carry a source of epinephrine at all times in case they have a dangerous allergic reaction.

Tree Nuts and Food Labeling Laws

Tree nuts are one of the most common food allergies, and as such, the U.S. Food and Drug Administration requires manufacturers selling foods in America to label foods containing tree nuts.

The Food Allergy Labeling and Consumer Protection Act (FALCPA) requires that manufacturers label which tree nut is in a given product.

Manufacturers are not required to mention the presence of tree nuts on manufacturing lines. Many do, however, due to consumer pressure. Because of the possibility of anaphylaxis, people with tree nut allergies should avoid products that mention the possibility of tree nut cross-contamination on labels.

Remember to always read your food packaging and ingredient labels, since ingredients and manufacturing practices can change at any time.

Foods that Contain Tree Nuts

Food that always or almost always contains tree nuts include:

  • Nutella (made from hazelnuts)
  • marzipan (almond paste)
  • pesto (unless specially prepared without pine nuts)
  • baklava
  • pralines
  • nut liqueurs (Frangelico, Amaretto, and Nocello)
  • nougat
  • turrón (a candy typically made with almonds)
  • gianduja (a creamy mixture of chocolate and chopped almonds and hazelnuts; other nuts can be used)
  • nut flours (almond flour is the most common)

Foods that may contain tree nuts include:

  • macaroons
  • granola bars
  • trail mix
  • cereal
  • fudge
  • caponata (a dish made from eggplant that often includes pine nuts)
  • ice cream
  • candy bars
  • baked goods
  • crackers
  • cookies
  • energy bars
  • flavored coffee
  • frozen desserts
  • marinades
  • barbecue sauces
  • mortadella (lunchmeat)
  • nougat
  • nut meal
  • natural extracts: almond and wintergreen (filbert/hazelnut allergy)

As with many common allergens, tree nuts are sometimes found in unlikely foods, so be sure to read labels on all packaged foods before buying or eating them.

Is Coconut a Tree Nut?

Many people consider coconut a fruit. When the FDA mandated that coconut be considered a tree nut for labeling purposes, it caused some confusion.

In fact, coconut allergy is uncommon, and studies have shown that people with tree nut allergy are at no greater risk of being allergic to coconuts. Many tree nut allergic individuals can tolerate coconut in milk and yogurt form. Talk to your allergist about including coconut if it is not currently part of your diet.

Eating Out with Tree Nut Allergies

Tree nuts aren't as common in restaurant cuisines as other allergens. However, the risk of a dangerous reaction makes eating out tricky.

Cuisines that may use nuts include:

  • Greek (some dishes use walnuts)
  • Chinese (cashews are included in many stir-fry dishes)
  • Mediterranean (almonds are common)
  • Italian (pesto is made with pine nuts)

In addition, high-end restaurants may use tree nut oils to make marinades and salad dressings. Japanese and Latin American cuisines are among the safer choices, but you should always err on the side of caution.

Risk of Anaphylaxis (Severe Allergic Reaction)

Tree nut allergy is among the top four allergens causing the most severe allergic reactions (the other three are peanut, fish, and shellfish).

If you also have asthma, you have a higher risk for a severe allergic reaction. For this reason, it's essential that anyone with a tree nut allergy learn the symptoms of anaphylactic shock and carry injectable epinephrine at all times.

A Word from Verywell

Managing your tree nut allergy depends on strict avoidance of the tree nuts that cause your allergic symptoms.

As the parent of a young child with a tree nut allergy, you'll need to involve a wide variety of adults in your child's life in order to keep your child safe, including caregivers, school teachers and administrators, and the parents of close friends.

There are some places where it may be difficult to avoid tree nuts. These include parties (where bowls of mixed nuts may be served) and bars. For this reason, it is important to teach children how to talk about their food allergy.

Anyone with a tree nut allergy (or caring for a child with a tree nut allergy) should be thoroughly briefed on reading labels, the symptoms of severe food allergies, and treating food allergies.

Sources:

Sicherer, Scott. Food Allergies. A Complete Guide for Eating When Your Life Depends on It. 2013. The Johns Hopkins University Press. Baltimore, MD.

Joneja, Janice Vickerstaff. The Health Professional's Guide to Food Allergies and Intolerances. 2013. Academy of Nutrition and DIetetics.

Continue Reading