**Background:** Food allergy (FA) is a growing public health concern, affecting an estimated 15 million people in the United States and causing approximately 30,000 emergency department visits and 150–200 deaths annually. Global FA prevalence ranges from 1% to 10%, with an estimated 2.5% according to the World Allergy Organization. In Lebanon, FA prevalence is estimated at 3.2% in adults and 4.1% in infants, with 6% of children affected as of 2022. Lebanon mandates the listing of 13 major allergens on prepackaged food labels (NL 206, 2017), including sesame, mustard, lupin, milk, soya, fish, egg, crustacean, peanut, nut, wheat, sulfite, and celery. However, precautionary advisory labeling (PAL) is not regulated, and data on consumer knowledge, attitudes, and practices (KAP) regarding allergen labeling in Lebanon and the MENA region are scarce. This study aimed to: (i) assess characteristics of FA labeling on packaged foods; (ii) verify compliance with Lebanese requirements; (iii) explore consumer KAP toward allergen labeling; and (iv) investigate sociodemographic determinants of KAP.
**Methods:** A market analysis of 1000 packaged food products was conducted at one multinational and one local supermarket chain in Lebanon between November 2020 and January 2021. Products were randomly selected across 14 categories; digital photographs were taken and verified. Information on ingredient lists, allergen declaration styles, and advisory statements was extracted. A descriptive cross-sectional online survey was conducted between January and March 2021 among Lebanese citizens or residents aged ≥18 years who participate in household grocery shopping. The target sample size was 720 participants (minimum 577 required based on WHO sample size calculations, assuming 50% prevalence, 95% CI, 5% margin of error, design effect 1.5, and 0.8 response rate). The survey assessed sociodemographics, purchasing habits, and KAP regarding allergen labeling. Knowledge scores were calculated out of 5 correct answers; attitude scores used a 5-point Likert scale. Chi-square tests compared emphasis types between local and imported products. Univariate and multivariate linear regression identified factors associated with knowledge and attitude scores, with results expressed as beta coefficients (β) with 95% confidence intervals.
**Key Results:** Of 1000 products analyzed, 951 had allergen labeling. Among these, 42.9% (408/951) carried PAL, with nine different precautionary statements identified. The most common was 'may contain traces of x' (59.6%), followed by 'may contain x' (27.7%) and 'our facility handles' (4.4%). Compliance with Lebanese standards was 94.1% for locally manufactured and 97.6% for imported products. The most frequently declared allergens in ingredient lists were wheat (64%, n=581), milk (50.9%, n=462), and soya (29.3%, n=266). Imported products more often used bold emphasis (60.5%) compared to local products (11%), while 51.7% of local products had no special emphasis (χ²=243.005, p=0.001). Seventy-two instances of ambiguous labeling were found (e.g., unspecified flour types, spices), and 27 discrepancies between ingredient lists and 'contains' statements were identified. Among the 541 survey respondents (89% response rate from 720 invited), mean age was 25.71±7.65 years, 81.8% were female, 86.3% were Lebanese, and 87.6% had university education. Self-reported food allergy prevalence was 25.3% (n=137), with 15.3% of these reporting a history of severe allergic reaction. The mean knowledge score was 2.16±0.98 out of 5. Notably, 77.4% of food-allergic respondents incorrectly believed PAL was required by law, and 42.3% believed advisory labels were based on allergen content amount. Among food-allergic respondents, 86.1% always checked ingredient lists, 54.7% always checked advisory statements, and 58.5% reported accidental allergen exposure (26.3% linked to failure to read a label, 16.1% to ignoring a precautionary statement). Regarding purchasing behavior, 17.5% always bought products labeled 'may contain allergens,' 41.6% always bought products labeled 'may contain traces of allergens,' and 59.1% always bought products labeled 'manufactured in a facility that also processes allergens.' Linear regression showed that living in the North governorate was associated with lower knowledge scores (β=−1.023, 95% CI: −1.678 to −0.367, p=0.002), and previous experience of a severe reaction was negatively associated with both knowledge scores (β=−1.43, 95% CI: −1.827 to −1.034, p<0.001) and attitude scores (β=−1.432, 95% CI: −2.798 to −0.067, p=0.04). Most respondents (89.1%) agreed or strongly agreed that generic terms (e.g., 'spices') were used in ingredient lists, and 68.6% suggested improvements such as larger font, allergen content information, and colorful symbols.
**Clinical Implications:** This study reveals critical gaps in consumer understanding of food allergen labeling in Lebanon. The high proportion of food-allergic individuals who misinterpret PAL as legally required, combined with the 58.5% rate of accidental exposures, indicates that current labeling practices inadequately protect consumers. The finding that 51.7% of local products lack any special emphasis on allergens, alongside 72 instances of ambiguous labeling and 27 discrepancies, highlights the need for regulatory reforms mandating clear, consistent, and conspicuous allergen declarations. The negative association between prior severe reactions and knowledge/attitude scores suggests that even affected individuals may lack adequate understanding, underscoring the need for enhanced educational interventions. Policymakers should consider requiring standardized PAL language, quantitative risk assessment, and visual cues (e.g., bold text, symbols) to improve label readability and consumer decision-making. Healthcare professionals should counsel food-allergic patients on proper label reading and the limitations of advisory statements. These findings are directly relevant to public health authorities, the food industry, and clinicians in Lebanon and the broader MENA region.