What should infants EAT? Dr Michael Perkin, Co-Principal - - PowerPoint PPT Presentation

What should infants EAT?

Anaphylaxis Campaign. 10th November 2016

Dr Michael Perkin, Co-Principal Investigator EAT Study Consultant in Paediatric Allergy & Senior Lecturer in Clinical Epidemiology

This presentation is dedicated to the memory of Sarah Reading and the tireless work of her father, David Reading, co-founder

• f the Anaphylaxis campaign.

The EAT study team hope the study might make a difference for all those who have been affected by food allergies.

www.eatstudy.co.uk Google FSA & EAT Study

Oral Tolerance Induction trials

High-risk strategy

• LEAP (P)
• STAR (E)
• PEAAD (P)
• BEAT (E)
• STEP (E)

Population strategy

• EAT (E, P, W, S, M, F)
• HEAP (E)
• PreventADALL (P, M, E, W)

LEAP-On n=556

LEAP and LEAP-On Studies

Consumption Avoidance

60 Months LEAP n=628 4 to < 11 Months 72 Months

Avoidance

Primary Endpoint: Persistent tolerance Comparison of proportion with peanut allergy in LEAP Consumers vs LEAP Avoiders at 72 Months Secondary Endpoint: Transient desensitization Comparison of proportion with peanut allergy in LEAP Consumers at 60 and 72 Months

81% Relative Reduction 74% Relative Reduction 89% Relative Reduction

Du Toit, G et al. Randomized Trial of Peanut Consumption in Infants at Risk for Peanut Allergy. N Engl J Med 2015; 372:803-813 Du Toit, G et al. Effect of Avoidance on Peanut Allergy after Early Peanut Consumption. N Engl J Med 4th March 2016

What about the study that can’t be named.....

LEAP nagged mothers into perfect compliance…

• Weekly phone calls from 4-11 months of age
• Fortnightly phone calls from 12-30 months of

age

• Monthly phone calls from 30 to 60 months of

age

A 4 month old LEAP family was phoned 104 times to remind them to eat peanut… Real world? …………..I think not……

81% Relative Reduction 74% Relative Reduction 89% Relative Reduction

Du Toit, G et al. Randomized Trial of Peanut Consumption in Infants at Risk for Peanut Allergy. N Engl J Med 2015; 372:803-813 Du Toit, G et al. Effect of Avoidance on Peanut Allergy after Early Peanut Consumption. N Engl J Med 4th March 2016

What about the study that can’t be named.....

• The good: After 12 months of peanut avoidance, peanut

allergy (PA) was still significantly higher in LEAP Avoidance group (18.6%) than LEAP Consumers (4.8%) at 72 months.

• The bad: 3 new cases of PA in LEAP control group
• The ugly: a massive 33% increase in peanut allergy in the

LEAP consumers after 12 months of avoidance from 3.6% at 60 months to 4.8% at 72 months

LEAP- Peanut Allergy Prevalence

Long standing tolerance by age 5....

Adherence to LEAP-On recommendation to stop eating peanut in consumption arm

0.00% 0.50% 1.00% 1.50% 2.00% 2.50% 3.00% Good as gold and stopped all peanut Bit naughty and ate some peanut Completely ignored the daft advice to stop eating peanut and ate loads

Conclusion: Need to eat peanut forever….

EAT Study Design

3 months 36 months 6 months

Recruitment and randomisation

Key Period of Intervention Outcome 12 months Clinic visit 3m Clinic visit 12m Clinic visit 36m

Monthly questionnaires

Ongoing Intervention & Follow Up

Three monthly questionnaires

EAT cohort

N=1303

Standard Introduction Group n=651 Early Introduction Group n=652 Tolerant Allergic Tolerant Allergic

N= 9416 Stage 3 mothers (infants aged 8-10 months) in the IFS 2010 4463 mothers were avoiding at least one food. 43% of these stated that the reason was a concern about allergies Avoidance of specific foods as ingredients was common. For egg (n=627), 24% avoided it because they considered it harmful and 44% because of concerns about allergies. For dairy products (n=484), 17% were concerned about harm, 50% allergies and 8% concerned with eczema. For nuts (n=2153) 33% were concerned about harm and 70% allergies (mothers could report more than one concern).

IFS 2010 – Allergen avoidance

Food Percentage giving food: 1/day or more 1-6 times a week <1/week

• r never

3/week

• r more

Cheese, yoghurt, fromage frais 64 26 9 85 Breakfast cereals 82 8 9 88 Bread 36 38 25 58 Eggs 2 23 76 6 Fish (incl. Tuna) 3 45 52 18 Nuts (incl. Ground nuts) <1 1 99 <1

Frequency of allergenic food consumption in UK infants aged 8-10 months

EAT Study Design

Standard Introduction Group (SIG) UK Infant feeding advice (based on WHO): exclusive breastfeeding for around 6 months with no introduction of wheat/gluten, eggs, fish, shellfish, nuts and seeds before 6 months. Early Introduction Group (EIG) Continued breastfeeding alongside sequential introduction of 6 allergenic foods: milk, egg, fish, peanut, sesame and wheat (aiming for 4g protein/week in 2 divided doses)

EIG Food portions

Introduced Allergenic Food Portion (containing 4g Protein) Median age intro (weeks) First Milk (40-60g yogurt) 17.3 Randomised Peanuts (3 rounded tsp peanut butter) 19.6 Randomised Fish (25g cod) 19.6 Randomised Sesame (3 rounded tsp tahini) 19.6 Randomised Egg (1 hard-boiled egg) 19.6 Last Wheat (2 weetabix) 20.6

EAT CONSORT Figure

1319 Participants were screened for EAT study 16 ineligible for enrollment: major health concerns identified from blood test results/clinical findings 1303 eligible infants enrolled in study 652 Were assigned to the Early Introduction Group 651 Were assigned tothe Standard Introduction Group 567 Were included in the ITT analysis 595 Were included inthe ITT analysis 56 Had missing data on outcomes 7 Exceeded visit window at final visit 6 Could not be evaluated by means of diagnostic algorithm 43 Withdrew voluntarily* 85 Had missing data on outcomes 9 Exceeded visit window at final visit 7 Could not be evaluated by means of diagnostic algorithm 69 Withdrew voluntarily* 31 Had missing dataon SIG adherence criteria SIG Adherence non-evaluable 81 Had missing dataon EIG adherence criteria EIG Adherence non-evaluable 564 Were evaluable for per-protocol adherence 524 40 SIG Per-Protocol SIG Non Per-Protocol 486 Were evaluable for per-protocol adherence 208 278 EIG Per-Protocol EIG Non Per-Protocol

80.5% 31.9%

Primary Outcome

Perkin M, Logan K, Tseng A et al. Randomized trial introducing allergenic foods in breastfed infants. March 4th 2016, at NEJM.org

Primary Outcome: Prevalence of Allergy to One or More Foods

ITT - 20% Non-significant reduction in prevalence in EIG PP - 67% Significant reduction in prevalence in EIG

Perkin M, Logan K, Tseng A et al. Randomized trial introducing allergenic foods in breastfed infants. March 4th 2016, at NEJM.org

Prevalence of Individual Food Allergy

Per-protocol – 100% Significant reduction in Peanut allergy prevalence in EIG Per-protocol – 75% Significant reduction in Egg allergy prevalence in EIG

Perkin M, Logan K, Tseng A et al. Randomized trial introducing allergenic foods in breastfed infants. March 4th 2016, at NEJM.org

EAT Results Conclusions

The EAT study failed to show efficacy in an intention-to-treat analysis. Further analysis suggests that the possibility of food allergy prevention through the early introduction of multiple allergenic foods in normal breastfed infants may depend on adherence and dosage.

Negative ITT, Positive PP Effect

• 1. The early introduction of allergenic foods prevented

food allergy developing.

• 2. Reverse causality.
• 3. Bias that could lead to increased atopy and food

allergy in children outside the per-protocol analysis is an important consideration given that only 31.9% (208/652) of all the enrolled early-introduction-group participants were per-protocol-evaluable versus 80.5% (524/651) in the standard-introduction-group.

• 4. Selective removal of baseline food allergic

participants exclusively from the early-introduction- group.

• 1. The early introduction of allergenic foods

prevented food allergy developing

This has some plausibility… Effect is potentially allergen specific

• 67% reduction in overall food allergy in per-protocol adherent EIG participants
• 100% reduction in peanut allergy in peanut per-protocol adherent EIG participants
• 75% reduction in egg allergy in egg per-protocol adherent EIG participants
• No allergy to sesame or wheat among sesame and wheat per-protocol adherent

participants respectively.

Effect suggests a dose dependent relationship

• Effectiveness of the intervention increased with the number of weeks the food was

eaten and the percentage of the recommended dose that was eaten.

• And for the EAT primary outcome with an increase in the number of foods that

were eaten

1 2 3 4 1 2 3 4

.05 .1 .15 .2 1 2 3 4 Mean weekly consumption (grams protein)

Food allergy

1 2 3 4 1 2 3 4

.05 .1 .15 .2 Probability of positive skin prick test 1 2 3 4 Mean weekly consumption (grams protein)

Skin prick test positive - 12 months

1 2 3 4 1 2 3 4 1 2 3 4

.05 .1 .15 .2 Probability of positive skin prick test 1 2 3 4 Mean weekly consumption (grams protein)

Skin prick test positive - 36 months

A Food allergy/skin prick test positive status: by quartiles of weekly allergen consumption

.05 .1 .15 .2 1 2 3 4 Mean weekly consumption (grams protein)

Food allergy

.05 .1 .15 .2 Probability of positive skin prick test 1 2 3 4 Mean weekly consumption (grams protein)

Skin prick test positive - 12 months

.05 .1 .15 .2 Probability of positive skin prick test 1 2 3 4 Mean weekly consumption (grams protein)

Skin prick test positive - 36 months

B Food allergy/skin prick test positive status: predicted probability plots by quartiles of weekly allergen consumption

. .

Peanut Egg Raw egg

• Individuals in EIG who did not follow the protocol may have

done so because of low level symptoms (food aversion or refusal) even in the absence of obvious clinical symptoms.

• These symptoms could have ultimately resulted in food allergy
• This would produce an artefactual decrease in the EIG per-

protocol food allergy rate by shifting food allergic patients early on towards non per-protocol adherence.

• 2. Reverse causality

1 2 3 4 5 6 7 8 9 10 SIG EIG SIG EIG SIG EIG Percentage

Primary outcome - food allergy to one or more foods

524 208

Per-Protocol

1 2 3 4 5 6 7 8 9 10 SIG EIG SIG EIG SIG EIG Percentage

Primary outcome - food allergy to one or more foods

524 208 40 278

Non Per-Protocol Per-Protocol

1 2 3 4 5 6 7 8 9 10 SIG EIG SIG EIG SIG EIG Percentage

Primary outcome - food allergy to one or more foods

524 208 40 278 31 81

Non Per-Protocol Per-Protocol Non-Evaluable Adherence

• 2. Reverse causality

Peanut Egg

Per-protocol compliance (overall)

A

≥4 foods ≥5 foods 6 foods

≥50% ≥75% 100% ≥50% ≥75% 100% ≥50% ≥75% 100% ≥4 weeks 81% (393/483) 69% (333/480) 54% (256/474) ≥4 weeks 74% (358/484) 58% (280/481) 40% (189/475) ≥4 weeks 57% (279/488) 41% (201/485) 24% (117/479) ≥5 weeks 68% (327/483) 54% (262/484) 35% (169/483) ≥5 weeks 58% (282/485) 43% (208/486) 25% (120/485) ≥5 weeks 42% (208/496) 25% (123/496) 12% (60/494) ≥6 weeks 57% (277/488) 42% (207/491) 25% (123/490) ≥6 weeks 45% (222/494) 26% (131/496) 16% (77/494) ≥6 weeks 25% (126/500) 13% (67/501) 6% (32/498)

SIG primary outcome allergy prevalence: SIG Per-Protocol 7.3% (38/524) SIG Non Per-Protocol 7.5% (3/40)

B

≥4 foods ≥5 foods 6 foods

≥50% ≥75% 100% ≥50% ≥75% 100% ≥50% ≥75% 100% ≥4 weeks 3.8%* (15/393) 3.3%* (11/333) 3.1%* (8/256) ≥4 weeks 3.1%* (11/358) 2.9%* (8/280) 1.6%** (3/189) ≥4 weeks 2.5%** (7/279) 2.5%* (5/201) 0.9%** (1/117) ≥5 weeks 3.7%* (12/327) 2.7%* (7/262) 3.0% (5/169) ≥5 weeks 3.2%* (9/282) 2.4%* (5/208) 2.5% (3/120) ≥5 weeks 3.4% (7/208) 0.8%** (1/123) 0.0%* (0/60) ≥6 weeks 3.2%* (9/277) 1.9%** (4/207) 1.6%* (2/123) ≥6 weeks 2.3%** (5/222) 2.3%* (3/131) 2.6% (2/77) ≥6 weeks 0.8%** (1/126) 1.5% (1/67) 0.0% (0/32)

*p<0.05 p<0.01

≥6 weeks ≥5 weeks ≥4 weeks 0% 1% 2% 3% 4% 5% 6% 7% 8% ≥50% ≥75% 100% 3.2% 1.9% 1.6% 3.7% 2.7% 3.0% 3.8% 3.3% 3.1% ≥6 weeks ≥5 weeks ≥4 weeks 0% 1% 2% 3% 4% 5% 6% 7% 8% ≥50% ≥75% 100% 2.3% 2.3% 2.6% 3.2% 2.4% 2.5% 3.1% 2.9% 1.6% ≥6 weeks ≥5 weeks ≥4 weeks 0% 1% 2% 3% 4% 5% 6% 7% 8% ≥50% ≥75% 100.00% 0.8% 1.5% 0.0% 3.4% 0.8% 0.0% 2.5% 2.5% 0.9%

≥4 foods ≥5 foods 6 foods

≥50% ≥75% 100% ≥50% ≥75% 100% ≥50% ≥75% 100% ≥4 weeks 3.8%* (15/393) 3.3%* (11/333) 3.1%* (8/256) ≥4 weeks 3.1%* (11/358) 2.9%* (8/280) 1.6%** (3/189) ≥4 weeks 2.5%** (7/279) 2.5%* (5/201) 0.9%** (1/117) ≥5 weeks 3.7%* (12/327) 2.7%* (7/262) 3.0% (5/169) ≥5 weeks 3.2%* (9/282) 2.4%* (5/208) 2.5% (3/120) ≥5 weeks 3.4% (7/208) 0.8%** (1/123) 0.0%* (0/60) ≥6 weeks 3.2%* (9/277) 1.9%** (4/207) 1.6%* (2/123) ≥6 weeks 2.3%** (5/222) 2.3%* (3/131) 2.6% (2/77) ≥6 weeks 0.8%** (1/126) 1.5% (1/67) 0.0% (0/32)

Per-protocol compliance (overall)

Koplin & Allen NEJM correspondence

1 2 3 Standard introduction Early introduction 4 5 6 7 8 9 10 11 12 4 5 6 7 8 9 10 11 12

Peanut - weekly cumulative frequency of consumption

Koplin & Allen NEJM correspondence

2 4 6 8 10 Standard introduction Early introduction 4 5 6 7 8 9 10 11 12 4 5 6 7 8 9 10 11 12

Egg - weekly cumulative frequency of consumption

• 3. Bias

Bias leading to increased atopy and food allergy in children

• utside the per-protocol analysis.

• 3. Bias

1319 Participants were screened for EAT study 16 ineligible for enrollment: major health concerns identified from blood test results/clinical findings 1303 eligible infants enrolled in study 652 Were assigned to the Early Introduction Group 651 Were assigned tothe Standard Introduction Group 567 Were included in the ITT analysis 595 Were included inthe ITT analysis 56 Had missing data on outcomes 7 Exceeded visit window at final visit 6 Could not be evaluated by means of diagnostic algorithm 43 Withdrew voluntarily* 85 Had missing data on outcomes 9 Exceeded visit window at final visit 7 Could not be evaluated by means of diagnostic algorithm 69 Withdrew voluntarily* 31 Had missing dataon SIG adherence criteria SIG Adherence non-evaluable 81 Had missing dataon EIG adherence criteria EIG Adherence non-evaluable 564 Were evaluable for per-protocol adherence 524 40 SIG Per-Protocol SIG Non Per-Protocol 486 Were evaluable for per-protocol adherence 208 278 EIG Per-Protocol EIG Non Per-Protocol

A A B B C C 80.5% 31.9%

• A. Participants non-evaluable for the primary
• utcome (EIG: 85, SIG 56)

Primary outcome evaluable (N=1178)* Both groups Primary outcome non-evaluable (N=125) Primary outcome evaluable vs non- evaluable p value Study Group (EIG) 48.9 60.8 0.01 Demography Siblings (any) (%) 61.0 73.6 0.006 Ethnicity (non-white) (%) 14.2 25.6 0.001 Maternal education (≤18 years) (%) 17.9 28.2 0.005 Smoking Maternal smoking (%) 2.9 6.5 0.03 Participant enrollment atopy status Visible eczema at 3m visit (%) 24.5 23.2 0.75 Scorad at 3m visit (median) (infants with eczema) 7.6 7.3 0.78 Skin-prick positive at 3m visit (%) 4.9 6.6 0.52 Participant post-enrollment atopy status Visible eczema at 12m visit (5) 26.3 21.6 0.45 Skin-prick positive at 12m visit (%) 15.8 25.5 0.07 Food allergy at 12m visit (%) ** 4.7 0.0 0.17 Family atopy status Maternal asthma (%) 26.6 23.6 0.47 Maternal eczema (%) 35.2 27.6 0.09 Maternal atopy (%) 63.7 52.0 0.01 Paternal atopy (%) 52.6 58.5 0.20

• B. Participants whose per-protocol status was

non-evaluable (EIG 81, SIG 31)

• C. Participants who were non per-protocol (EIG

278, SIG 40)

SIG EIG

Per-Protocol status Per-Protocol status Per-Protocol (N=558) Non Per-Protocol (N=48) Adherence Non- Evaluable (N=45) Per-Protocol (N=223) Non Per-Protocol (N=306) Adherence Non- Evaluable (N=123) Primary outcome evaluable %(n) 93.9 (524) 83.3 (40)† 68.9 (31)‡ 93.3 (208) 90.8 (278) 65.9 (81)‡ Demography Sex (male) (%) 49.5 45.8 31.1* 49.3 53.6 52.0 Siblings (any) (%) 62.0 56.3 64.4 59.6 64.1 64.0 Ethnicity (non-white) (%) 15.1 16.7 26.7* 7.2 16.3† 23.6‡ Pet ownership (any) (%) 43.4 58.3* 45.5 45.7 39.5 33.6* Maternal education (≤18 years) (%) 19.5 14.6 29.6 16.6 17.3 22.0 Smoking Maternal smoking (%) 2.3 8.3 6.8 3.6 2.6 4.9 Father smoking (%) 9.5 16.7 22.7† 11.2 10.5 10.7 Birth history Caesarean delivery (%) 21.9 20.8 35.6* 24.7 29.1 29.3 Enrollment atopy status Visible eczema at 3m visit (%) 24.2 25.0 22.7 20.2 28.1* 23.6 Scorad at 3m visit (median) (infants with eczema) 7.4 9.4 15.7 7.4 8.6 7.1 Skin-prick positive at 3m visit (%)

• 4.0

5.2 6.5 Eczema natural history New onset eczema (4-6m) (%) 11.3 8.3 5.9 10.4 12.6 2.4 Family atopy status Maternal asthma (%) 27.1 22.9 27.3 26.5 28.1 18.9 Maternal atopy (%) 63.3 60.4 65.9 60.1 64.7 58.2 Paternal atopy (%) 57.0 50.0 45.5 51.1 51.0 48.4 Maternal factors Maternal QOL at 3m mean (SD) Physical QOL 16.4 (2.0) 16.8 (1.7) 15.6 (2.6)* 16.7 (1.9) 16.5 (1.7) 16.4 (1.9) Psychological QOL 15.6 (1.9) 15.6 (1.7) 14.8 (2.4)* 16.0 (2.1) 15.4 (2.0)† 15.2 (2.2)† Social QOL 15.7 (2.7) 15.6 (2.6) 14.3 (2.8)† 15.8 (2.8) 15.4 (2.8) 15.3 (2.6) Environment QOL 16.3 (2.0) 16.6 (1.6) 15.2 (2.4)‡ 16.6 (2.0) 16.3 (1.7) 16.3 (1.9)

1 2 3 4 5 6 7 8 9 10 SIG EIG SIG EIG SIG EIG Percentage

Primary outcome - food allergy to one or more foods

524 208 40 278 31 81

Non Per-Protocol Per-Protocol Non-Evaluable Adherence

• 4. ARTEFACT OF STUDY DESIGN

The selective removal of baseline food allergic participants exclusively from the EIG

• 7 baseline visit food allergic participants in the EIG
• 5 of whom were primary outcome positive by 3 years of age
• These 5 were unable to be per-protocol adherent, thus

artificially reducing the food allergy rate in the per-protocol group

ID Skin-prick test (mm) at 3m Enrollment challenge

• utcome

EIG per-protocol status Peanut consumption at 6 months Egg consumption at 6 months Milk consumption at 6 months Sesame consumption at 6 months Fish consumption at 6 months Wheat consumption at 6 months Study primary

• utcome

status Baseline food allergic (n=7) 1 RE5 E+ Non-evaluable Not tried yet5 Not tried yet5 50%5 Not tried yet5 Not tried yet5 Not tried yet5 Indeterminate 2 M5 M+ Non-evaluable 100%7 100%7 Not tried yet7 100%7 100%7 100%7 Positive (E) 3 M6 P2 M+ P+ No Not tried yet 100% Not tried yet 100% 100% 100% Negative 4 M5 RE16 M+ Eind No 50% Not tried yet Not tried yet 50% 50% 75% Positive (PE) 5 RE7 E+ 100%7 Not tried yet7 100%7 100%7 75%7 75%7 Positive (E) 6 M7 P4 M+ P+ No Not tried yet 50% Not tried yet 25% or less 100% 100% Positive (M) 7 RE3 P3 W2 E- P- W+ No 50%7 100%7 100%7 50%7 100%7 Not tried yet7 Positive(EPW)

Prevalence of Allergy to One or More Foods

Adjusted PP - 62% Significant reduction in prevalence in EIG

Perkin M, Logan K, Tseng A et al. Randomized trial introducing allergenic foods in breastfed infants. March 4th 2016, at NEJM.org

Negative ITT, positive PP effect

1. The early introduction of allergenic foods prevented food allergy developing. 2. Reverse causality. 3. Bias that could lead to increased atopy and food allergy in children outside the per-protocol analysis is an important consideration given that only 34.2% (223/652) of all the enrolled early-introduction-group participants were per- protocol-evaluable versus 85.7% (558/651) in the standard-introduction-group. 4. Selective removal of baseline food allergic participants exclusively from the early-introduction-group. Nevertheless we cannot be certain that unmeasured sources

• f bias may still exist.

Comments on the quality and robustness of the design, methodology and interpretation of the EAT study?

Design and Methodology

• Largest early food introduction RCT published to

date

• High follow up
• 70/74 food allergy diagnoses confirmed by gold

standard DBPCFC

• ALL sensitised participants challenged
• Low adherence in EIG
• EAT real world (effectiveness) versus LEAP proof
• f principal (efficacy)
• SIG - gold standard...
• EIG - ?too many foods, ?dose

Are EAT study participants representative of the general population?

Representativeness

• 82% of EAT participants had a parental history of atopy (mother and/or father with

self-reported asthma, eczema or hay fever) IFS 2010 51% (for the above conditions and self-reported food allergy in either parent or a sibling) reported in the IFS2010. IFS2010 managerial/professional mothers (more similar to EAT mothers) 56%

• EAT Filaggrin mutation rate (11.9%).

Versus Isle of Wight cohort study (10.3%) and Irish birth cohort study (10.5%) Studies assessing unselected cohorts of 3 month old infants are rare.

• EAT visible eczema rate at 3 months (24.4%) higher than in the 6 month old infants

examined in the Irish cohort study (18.7%), using the same diagnostic criteria, Although the mean SCORAD amongst those with eczema was significantly higher in the Irish study than our study.

• Sensitisation rate in the EIG in EAT was higher than the 1.2% observation in the

DARC cohort Latter only tested for two foods, milk and egg, and used only a commercial skin prick test solution for the latter.

Could these findings be relevant to a high risk population?

Relevance to high risk population?

• No one excluded from participation
• Only 9 out of the 1303 participants in EAT

would have been eligible to enrol in LEAP based on the SCORAD criteria (greater than 40).

• 76% of the standard-introduction-group did

not have eczema at 3 months of age and yet they accounted for 38% of the overall burden

• f food allergy

What to tell patients?

• EAT works – if you do it
• It doesn’t increase risk of food

allergy if you don’t

• It is safe

So feed your children and hope that they will eat.

EAT

Research Fellow/Study Manager Dr Kirsty Logan Dieticians Ms Bunmi Raji Ms Anna Tseng Ms Sarah Nesbeth Ms Charlotte Stedman Clinicians Dr Michael Perkin (Co-PI) Professor Lack (PI) Dr Tom Marrs Dr Carsten Flohr Data Manager Ms Joanna Craven Research nurses Ms Louise Young Ms Mary DeSouza Mrs Vicky Offord Mr Jason Cullen Ms Katherine Taylor Recruiters/Administrators Ms Sharon Tonner Ms Emily Banks Ms Yasmin Kahnum Dr Rachel Babic Dr Ben Stockwell Ms Erin Thompson Ms Lorna Wheatley Laboratory staff Dr Victor Turcanu Mr Alick Stephens Ms Asha Sudra Ms Ewa Pietraszewicz House dust project Dr Helen Brough Ms Kerry Richards Phlebotomist Ms Devi Patkunam External experts Ms Kate Grimshaw Ms Rebecca Knibb Trial Steering Committee Professor Graham Roberts (chair) Professor David Strachan (vice chair) Dr Mary Fewtrell Professor Christine Edwards Mr David Reading Professor Ian Kimber Professor Janet Peacock Dr Salma Ayis Food Standards Agency Dr Joelle Buck Ms Sarah Hardy Miss Elizabeth Kendall Ms Shuhana Begum Coverage support Ms Gemma Deutsch Dr George du Toit