The Tree Nut Allergy Diet Guide

Everything You Need to Know to Get Started

almond granola
Read ingredient list for possible tree nuts.. Jill Castle, MS, RD

In the U.S., an allergy to tree nuts affects about 0.5% of the population. There are many tree nuts including the most common: macadamia nuts, brazil nuts, cashews, almonds, walnuts, pecans, pistachios, chestnuts, hazelnuts (filberts), and pine nuts (pignoli or pinon). Less common tree nuts are beechnut, butternut, chinquapin, gingko, hickory nuts, lychee nuts, pili nuts and shea nuts. Tree nuts frequently cause strong allergic reaction and may cause anaphylaxis.


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 it. For this reason, it is recommended that children be reevaluated periodically by a board certified allergist. Children who are allergic to multiple types of tree nuts (more than one or two) are less likely to outgrow their allergy. 

Allergy to More than One Tree Nut:

People can be allergic to one, or some tree nuts, and not others. Some tree nuts contain similar proteins, such as almonds and hazelnuts, walnuts and pecans, or pistachios and cashews. Because of the protein similarities, it is common for an individual to have allergy to both nuts. For instance, if you are allergic to cashew, you have a greater risk of being allergic to pistachios also.

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. 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.

Allergy to tree nut and peanut are two unique allergies. While people allergic to tree nuts are not necessarily allergic to peanuts, one can be allergic to both. 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 are:

People with tree nut allergy should carry a source of epinephrine at all times, in the event of anaphylaxis.

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 more confusion. Coconut allergy is uncommon. A 2009 study of 37 children allergic to tree nuts and peanuts were evaluated for incidence of coconut allergy and found to be at no higher risk of allergy to coconut.

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 daily diet.

Foods With Tree Nuts:

Labeling laws require tree nut ingredients to be identified. Remember to always read your food packaging and ingredient labels. Ingredients can change, as well as manufacturing procedures. 

Food that always or almost always contains tree nuts include:

  • Nutella
  • marzipan (almond paste)
  • pesto (unless specially prepared without pine nuts)
  • baklava
  • pralines
  • nut liqueurs (Frangelico, Amaretto, and Nocello)
  • nougat
  • turrón
  • gianduja (a creamy mixture of chocolate and chopped almonds and hazelnuts; other nuts can be used)

Foods that may contain tree nuts include:

  • macaroons
  • granola bars
  • trail mix
  • cereal
  • fudge
  • caponata
  • ice cream
  • divinity
  • candy bars
  • baked goods
  • crackers
  • cookies
  • energy bars
  • flavored coffee
  • frozen desserts
  • marinades
  • barbeque 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.

Labeling Laws Affecting Tree Nut Allergy:

Tree nuts are one of the most common food allergies, and as such, the FDA 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.

Eating Out with Tree Nut Allergies:

While tree nuts are not as prevalent as some other allergens, the risk of anaphylaxis makes them dangerous to consume outside of the home. The chance of cross-contact and other dangers exist when dining out, so call the restaurant ahead of time and discuss your diet with a manager or the chef.

Some risky cuisine for nut allergies are:  Greek: several common dishes use walnuts; Chinese:  cashews may be used in the dishes; Mediterranean: almonds are featured in the food; Italian: Pesto, made with pine nuts, is likely to appear on the menu. 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 always err on the side of caution.

The Risk of Anaphylaxis:

Tree nut allergy is among the top four allergens causing the most severe allergic reactions. Allergy to peanut, fish and shellfish round out the other three. If asthma is a co-existent condition, the risk for severe anaphylaxis is higher. 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.

Managing Tree Nut Allergy:

Management of a tree nut allergy depends on strict avoidance of the tree nut (s) that cause your allergic symptoms. For young children, the collaboration of a wide variety of adults including parents, caregivers, school teachers and administrators, and parents of close friends is needed to keep children safe from ingestion and reaction.

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.

Families dealing with tree nut allergies are likely to find at least some systems in place for dealing with allergies in many institutions. Here are some resources you may find useful:

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.


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