Imagine a busy school lunchroom. Suddenly, a child collapses. One possible cause: a food allergy. Imagine a busy food court on a college campus. A co-ed suddenly begins vomiting. The cause: a reaction to a food allergy.

Imagine a busy corporate dining room. An executive about to leave for an important presentation finishes off his dessert, unaware that it had nuts in the crust. Suddenly, because he is allergic to them, he finds himself breaking out in hives. All these scenarios are possible and could easily happen in your operation. As many as 2.5% of the U.S. population, or 6.8 million Americans, have true food allergies. When exposed to the wrong foods even in ordinary circumstances, these individuals can have serious—sometimes even deadly—reactions.

A greater public awareness of the extent of this problem has made it increasingly important for FSDs to understand which foods cause allergic reactions, what symptoms to look for and, most importantly, how to handle a food allergy incident.

“Understanding food allergies and knowing how to prevent and treat an incident can mean the difference between life and death,” says Anne Muñoz-Furlong, founder/CEO of The Food Allergy & Anaphylaxis Network, a Fairfax, Virginia- based advocacy group.

“Today we’re seeing a lot more foodservice professionals looking to educate themselves about these problems and for ways to minimize the chance of having food allergy incidents in their cafeterias,” she adds. “But there’s still a lot of work to be done.”

The few but mighty

While there’s no definitive data on the prevalence of food allergies, experts say that the largest affected group is children. “We’re definitely seeing an increase in the number of students who report with this problem,” says Carol Kehrer, director of Champ’s Cafe at Charlotte County Public Schools, Punta Gorda, FL. “At one of our Head Start schools last year, half the 140 students enrolled listed some kind of food allergy.” FSDs in healthcare and higher education report similar increases.

“We used to have one or two patients on allergy diets at any given time. Now we have 15 or more,” says Mary Keysor, director of food and nutrition services at Maine Medical Center, Portland. “I am finding more challenges in the retail side of my business as well, as more customers want access to recipe and ingredient lists.”

Muñoz-Furlong says a few theories exist as to why food allergies seem to be more prevalent today.

• There is greater awareness of the problem and quicker diagnoses because of increased media coverage. Symptoms attributed to other causes in the past may actually have been food allergy reactions.

• Changing diets mean that more proteins are being introduced to children at younger ages, sometimes before their immune systems are prepared to handle them; experts say this may result in food allergies; and

• Cleaner environments have eliminated many of the bacteria our immune systems used to battle, so the systems may instead be turning on certain ingested foods.

The eight main culprits

Essentially, a food allergy is an abnormal response by the body’s immune system to a food protein. When the dangerous food is eaten, the body releases histamine and other chemicals to “attack” the food, causing anaphylaxis (a severe reaction). Symptoms generally occur within a period that ranges from a few minutes to up to two hours.

These can include a tingling sensation in the mouth, a swelling of the tongue and the throat, difficulty breathing, an outbreak of hives (large reddish “wheals” that appear suddenly on skin areas), vomiting, abdominal cramps, diarrhea, a drop in blood pressure, loss of consciousness and (in the most severe cases) sudden death.

Food allergies are the leading cause of anaphylaxis outside a hospital setting. Experts estimate that up to 200 deaths per year can be attributed to them. Currently, there is no cure.

It is important to note that true food allergies are different from simply having an “intolerance” to certain foods. For example, a lactose intolerance is not the same thing a food allergy. Food intolerance is an adverse food-induced reaction that does not involve the immune system.

Fortunately, only eight common foods account for 90% of all allergic reactions. Unfortunately, these foods (or by-products of them) appear in a wide variety of menu items, and pre-packed foods, and are common ingredients. They are: milk, eggs, wheat, soy, peanuts, tree nuts, fish and shellfish.

Any person of any age can be allergic to these foods, but Muñoz-Furlong says that infants and younger children are more likely to be allergic to milk and soy; older children to eggs, wheat and peanuts; and adults to fish and shellfish.

Many children grow out of their allergies as they mature (especially those with allergies to milk, soy, eggs and wheat), although some have to continue to monitor what they eat for the rest of their lives. In any case, every foodservice director should familiarize him or herself with the symptoms of food allergies and about what to do in case of an incident.

Be prepared

Adults with food allergies, including college students, are usually more prepared to deal with such challenges and therefore need less supervision. On college campuses, for example, many FSDs provide professional dietary counseling to address the problem. They also typically arrange to let allergic students opt out from or modify standard meal plans.

Muñoz-Furlong recommends some specific strategies FSDs can use to help eliminate food allergy-related incidents and to deal with them more effectively when they occur. While most apply to school-aged children and school foodservice settings, many can be modified for use in other segments.

Learn everything you can about food allergies, their causes, symptoms and what steps to take in the event of an incident. You don’t have to be an expert, Munzo-Furlong says, but you have to know enough to recognize the symptoms when they occur and know what you can do to help.

All foodservice staff, especially those preparing food, should be familiar with key technical and scientific words describing foods associated with allergic reactions. For example, non-dairy products often contain casein, a milk by-product that is dangerous for those with dairy allergies. It’s also a good idea to keep an updated binder on hand in the kitchen and cafeteria that lists the ingredients in the food items you serve, so that both staff and customers can easily access this information if it is needed.

Be part of your organization’s food allergy team. This advice is directed primarily to school nutrition directors who work in situations where principals and school nurses are involved. Most parents of children who suffer from food allergies seek out principals and nurses to provide information about their children before they start school. For one reason or another, an FSD may not be aware of this information (even though, obviously, he or she should be).

“In some cases, school nurses are concerned about patient confidentiality and will not divulge students’ medical conditions to non-medical professionals,” Munzo-Furlong says.

“If that is the case, and you know that a student who eats in your cafeteria has a food allergy, call the parents directly. Talk to them about what he or she can or can’t eat or be exposed to, and give them your direct phone number so that they can call you with questions. It’s a good idea to do this even if you are part of the allergy team. In most cases, parents will be grateful that you are taking an interest in the child’s safety.”

Also, remember that many children grow out of their allergies, so your team’s plan for each child needs to be updated as the child ages.

Identify menu substitutions for allergy suffers. School FSDs report that allergy sufferers generally bring their own lunches from home. But if an allergic student chooses to eat in the cafeteria, the parents should inform the cafeteria staff in writing about foods that need to be avoided and suggest “safe” substitutions.

Consider designating specific seating areas for allergy suffers. This area should be clearly marked and free of the offending food (e.g., a peanut butter-free table). At first glance, it might seems that such seating areas would stigmatize a child, but Muñoz-Furlong says that’s not necessarily the case.

“Other children can come to view the table as ‘special,’ and want to eat there, too,” she says. “We also recommend that FSDs institute the Protect A Life (“PAL”) program that assigns an allergyfree child to be a “buddy” for each allergy suffer. That child can then notify an adult if there is an emergency.”

Don’t simply ban foods, like peanut butter, if you can avoid it. Peanut allergies seem to be the most common among schoolaged children and it’s tempting to just ban all peanut butter and peanut-related products in order to eliminate problems.

“It’s not that easy,” Munzo-Furlong notes, “because you can’t control what foods kids bring in from home.” Plus, as many parents will point out, peanut butter and jelly sandwiches are a lunch staple and asking non-allergy children to avoid this favorite may be viewed as a sign of discrimination.

Janet Beer, director of nutrition services for Portland (OR) City Schools, says that in one of her elementary schools, concern about peanut allergy is high, and “every child is handed a sanitized handwipe as they leave the cafeteria and expected to use it. The idea is to help ensure that none of the foods that touched or remain on their hands is transferred to the playground equipment.”

Make sure that “red flag” ingredients are obviously displayed near food that contains them, if possible. Food allergy sufferers should be able to visually inspect a dish or food item and know immediately if it contains an item they can’t eat.

It is also a good idea to name potentially problematic menu items so they clearly indicate allergy-inducing ingredients. For example, if a dessert has walnuts, call it “Apple Walnut Squares” or an entrée with peanut sauce, “Peanut Chicken Stir-fry.” In addition, put ingredient cards on display that identify a dish’s main ingredients and also note any common “red flag” ingredients.

Eliminate possibilities for cross contamination. Taking steps to avoid cross contamination can prevent many allergy-related problems. One example: When preparing peanut butter and jelly sandwiches, don’t use the same knife to apply both spreads. If possible, designate one area of the kitchen for preparation of foods that may induce allergic reactions. Use color-coded utensils (including knifes and cutting boards) for different foods (i.e. dairy products, nut-related products, etc.). If this isn’t feasible, prepare these foods on disposable plates using disposable utensils.

Finally, be sure to use clean towels and wipes to clean up and sanitize designated allergy-free tables before lunch periods. Don’t use the same towels or wipes employed elsewhere in the cafeteria.

Institute a “no food and/or utensil trading” rule. Muñoz- Furlong says that most outbreaks occur because children trade foods and or utensils. Instead of trying to monitor this activity, she suggests outlawing it altogether in order to avoid peer pressure.

Identify customers who suffer from food allergies and those who have been prescribed epinephrine (a common medicine to treat anaphylaxis). Photos of each child, along with his or her name and specific allergy, warning signs of reactions and emergency treatment plan should be posted in the kitchen (not in the cafeteria, for purposes of confidentiality.) Make sure everyone on the foodservice staff is familiar with this child or children so that they can quickly recognize a child who may be having an allergic reaction.

At Charlotte County Public Schools, the names of children who suffer from food allergies and the foods they can and cannot buy are flagged in the foodservice department’s P.O.S. system so that cashiers can remove allergy-inducing foods from their trays. The cashiers suggest that these students choose an alternative food.

Know what to do in case of a food-allergy emergency. Acting quickly is key and in order to do so, FSDs and other foodservice staff must know how to treat a child suffering from anaphylaxis. The most common treatment is epinephrine, which is generally injected (it is available in several self-administration devices).

Treatment protocols need to be prescribed by a physician. The school staff, including the FSD, should have written instructions from the child’s physician and signed by the parents, providing easy-to-follow steps for recognizing a reaction and administering medication. It should be kept in locations that are easily accessible and not locked in cupboards or drawers. Older children often carry their own emergency kits. Know and closely follow administration guidelines for any use of medication.

Be aware that product substitutions can lead to problems. It is common for suppliers to substitute a similar product when an operator’s original order can not be fulfilled, but this can be a real danger if the substituted product is formulated differently.

“We use a plain chicken breast that we selected because it has a minimal number of ingredients and additives,” says Maine Medical Center’s Keysor. “We recently had a situation in which our supplier was out of our specced chicken breast and substituted a very similar product. However, that product contained soy. If my staff had not done a great job of checking on the ingredients, we might have served it to a patient who was allergic to soy.”

Keysor and other directors would like to see manufacturers make product ingredient lists more easily accessible so that they can better manage the growing food allergy challenge.

“I would like manufacturers to provide electronic access to complete product ingredient lists and to notify us of any change in ingredients that affect their products,” Keysor says.

A Tool for Managing Food Allergies For a limited time (as long as supplies are available), the Food Allergy Network is offering a comprehensive program for managing food allergies in schools. Entitled, “The School Food Allergy Program,” the kit consists of a three-ring binder and video that provide guidelines school FSDs can use to train their staffs about food allergy causes and symptoms and the steps to take in case of a food-related emergency. It also offers guidelines for principals, school nurses, teachers and a glossary of related terms. Additionally, the kit contains free materials for creating a Be a PAL (Protect a Life) program (see main story). The kit costs $75.To purchase or for more information, log onto www.foodallergy.org or call 703-691-3179.