Food allergy management among restaurant workers in a large U.S. city

Investigating Motivators for Managing Customers with Food Allergies in Ethnic Restaurants

ABSTRACT

Food allergic reactions frequently occur in ethnic restaurants. However, effective training materials specific to food allergies have not been readily available to employees. The objectives of the study were to investigate employee self-efficacy, perceived susceptibility, and commitment on the basis of individual and operational factors and what variables, among self-efficacy, perceived susceptibility, and commitment, are associated with the employee's intention to reduce risky behavior when handling food allergies in ethnic restaurants. A total of 256 employees who had or are currently working in ethnic restaurants and had direct contact with food or customers participated in this study through the Amazon Mechanical Turk Web site from October 2020 to April 2021. The statistical analysis results showed that employee self-efficacy, perceived susceptibility, and commitment vary on the basis of gender, food safety certification, training, and availability of menu items for customers with food allergies. In addition, employee self-efficacy, perceived susceptibility, and commitment are positively correlated with employee's risk reduction behavior for food allergies. The results of the study will provide practical guidelines for developing more multidimensional training programs specific to food allergies in ethnic restaurants.

HIGHLIGHTS

An International First: Stakeholder Consensus Statement for Food Allergen Management in Packaged Foods and Food Service for Australia and New Zealand

Food-allergic consumers encounter inadequate, confusing, and ambiguous allergen information for packaged and unpackaged foods. Key Australian and New Zealand allergy organizations convened multiple forums to facilitate discussions among consumers, food manufacturers, food retailers, regulatory bodies, researchers, and health professionals to develop a unified approach to improving food allergen management. The following stakeholder consensus statement provides a foundation for advocacy for improved food allergen management and safety. It is the responsibility of consumers to: 1. declare their food allergies and read food labels (including ingredient lists and allergen declaration statements), and 2. ultimately make their own judgment about the foods they choose to consume. We consider that to enable consumers to make informed decisions about their safety, It is the responsibility of packaged food manufacturers to: 1. follow robust allergen management practices including quantitative risk assessment, and 2. use clear, consistent labeling to inform consumers about that food's allergen content, including the possible presence of unintended allergens. It is the responsibility of food service establishments and providers to: 1. follow robust allergen management practices, and 2. ensure that staff understand and can inform consumers about the allergen content of the food they provide, including the possible presence of unintended allergens.

Food Allergy in Restaurants Work Group Report

Individuals with food allergy are at risk for accidental exposures, potentially resulting in allergic reactions that may cause significant morbidity and mortality. Dining out, including restaurants or take-out, account for a large proportion of severe reactions. Errors due to gaps in knowledge or miscommunication can easily occur on behalf of food-allergic individuals or restaurant staff, resulting in accidental exposures and allergic reactions. Improved legislation, training of restaurant staff, and practitioner-guided education are recommended to reinforce patient safety and prevent severe allergic reactions. This Work Group Report provides guidance with specific practices that practitioners may recommend, and that patients and restaurant staff may employ, for prevention and treatment of food-allergic reactions in restaurants.

The global burden of illness of peanut allergy: A comprehensive literature review

Peanut allergy (PA) currently affects approximately 2% of the general population of Western nations and may be increasing in prevalence. Patients with PA and their families/caregivers bear a considerable burden of self‐management to avoid accidental peanut exposure and to administer emergency medication (adrenaline) if needed. Compared with other food allergies, PA is associated with higher rates of accidental exposure, severe reactions and potentially fatal anaphylaxis. Approximately 7%–14% of patients with PA experience accidental peanut exposure annually, and one‐third to one‐half may experience anaphylaxis, although fatalities are rare. These risks impose considerably high healthcare utilization and economic costs for patients with PA and restrictions on daily activities. Measures to accommodate patients with PA are often inadequate, with inconsistent standards for food labelling and inadequate safety policies in public establishments such as restaurants and schools. Children with PA are often bullied, resulting in sadness, humiliation and anxiety. These factors cumulatively contribute to significantly reduced health‐related quality of life for patients with PA and families/caregivers. Such factors also provide essential context for risk/benefit assessments of new PA therapies. This narrative review comprehensively assessed the various factors comprising the burden of PA.

Characteristics of Food Allergic Reactions in United States Restaurants

BACKGROUND

Food allergic reactions of varying severity occur in restaurants. Studies to date have shown that there are gaps in knowledge of and communication between restaurant staff and food allergic individuals.

OBJECTIVE

We sought to characterize allergic reactions in restaurants to better inform the restaurant industry, food allergic individual, and allergist so that mitigation strategies can be implemented.

METHODS

Data collected over a 2-year period from 2822 individuals in the Food Allergy Research & Education registry were analyzed using descriptive statistics.

RESULTS

Dining out accounted for the second most common location for a food allergic reaction, after one's home, and many were severe with 28.0% requiring 1 dose and 6.2% requiring 2 doses of epinephrine. Cafes, fast food establishments, and Asian restaurants were frequently implicated sites. Peanut, tree nuts, and milk were the most common inciting allergens, and tree nuts resulted in the most common use of epinephrine. Of the allergic reactions, 53.9% occurred despite conveyance of food allergy to restaurant staff, 26.6% occurred when allergens were declared on the menu, and 13.7% occurred when allergens were declared on the menu and restaurant staff were informed of a food allergy.

CONCLUSIONS

Allergic reactions in restaurants are common and can be severe. Findings presented here underscore the need for restaurant staff training and mandatory declaration of allergenic ingredients in meals. This updated knowledge will help support advocacy efforts and inform patients, allergists, and the restaurant industry on best practices for dining out to improve the quality of life for food allergic individuals.

Food Allergy Management at School

BACKGROUND

Approximately 8% of schoolchildren in the United States experience potentially life-threatening food allergies. They must diligently avoid allergenic foods and have prompt access to epinephrine to treat anaphylaxis. These prevention strategies must be sustained without interruption, posing a range of challenges at school.

METHODS

We conducted semi-structured interviews with 178 participants about their experiences managing food allergies outside the home. Interviews were transcribed and analyzed using an iterative approach in NVivo 10.

RESULTS

Participants reported highly varied school experiences across the ecological model. They described the need to be proactive and self-sufficient to manage food allergies. Whereas food allergy-related social exclusion was common, participants also described positive peer interactions, including intensive peer engagement and support. They perceived that formal school policies were limited in scope and inconsistently implemented. Prevention-oriented policies were more common in lower grades than in higher grades.

CONCLUSIONS

Poorly defined and implemented policies disrupted students' social and educational experiences at school, families' relationships with school staff, and, ultimately, the safety and wellbeing of students with allergies. Given the high prevalence of food allergies among children, these findings demonstrate the need for multiple layers of support to facilitate safe, socially inclusive food allergy management at schools.

Use of IHF-QD Microscopic Analysis for the Detection of Food Allergenic Components: Peanuts and Wheat Protein

The aim of the study was to analytically evaluate quantum dots in immunohistofluorescence (IHF-QD) microscopic imaging as detectors of food allergens—peanut and wheat. The experiment was designed as two in silico experiments or simulations: (a) models of pastry samples were prepared with the addition of allergenic components (peanut and wheat protein components) and without the addition of allergenic components, and (b) positive and negative commercial samples underwent food allergen detection. The samples from both simulations were tested by the ELISA and IHF-QD microscopic methods. The primary antibodies (secondary antibodies to a rabbit Fc fragment with labeled CdSe/ZnS QD) were labelled at 525, 585, and 655 nm emissions. The use of quantum dots (QDs) has expanded to many science areas and they are also finding use in food allergen detection, as shown in the study. The study indicated that differences between the ELISA and IHF-QD microscopic methods were not observable among experimentally produced pastry samples with and without allergenic components, although differences were observed among commercial samples. The important value of the study is certainly the differences found in the application of different QD conjugates (525, 585, and 655). The highest contrast was found in the application of 585 QD conjugates that can serve for the possible quantification of present food allergens—peanuts and wheat. The study clearly emphasized that QD can be used for the qualitative detection of food allergens and can represent a reliable analytical method for food allergen detection in different food matrixes.

Food allergen knowledge, attitude and practices among UK consumers: A structural modelling approach

Food allergies are becoming more prevalent and affect up to 1-2% of adults and 5-8% of children in the UK. This study investigated the food allergen knowledge, attitude towards food allergens and food allergy management practices among food allergic and intolerant consumers and/or their family members and carers. Questionnaires were distributed at three major Free From events in the UK in 2017 and 2018. Structural Equation Modelling (SEM) was used as a confirmatory technique to determine the model's validity. Cereals containing gluten, milk and eggs were the most common triggers reported by the consumers. Other trigger foods such as chocolate, garlic, maize, onions, red and white meat, spices, and fruits such as apples and cherries were also reported. Consumers demonstrated very good understanding on the severity of allergic reactions, prevention method and hidden egg ingredients. Overall, consumers were relatively good in the knowledge section. The participants were motivated in their personal allergen avoidance towards food allergens especially in checking food labels, preference for more free from product choices and handwashing. Consumers did not rely on dietary apps or social media to find out about allergen-free food products. Both knowledge and attitude did not translate into food allergy management practices. Significant correlation between knowledge and attitude was identified suggesting that as knowledge decreases, so will their attitude scores. This study suggests that targeted and systematic food allergy management topics and peer support could be used to improve consumers' knowledge and attitude to positively impact food allergen handling practices.

Food Allergies: Knowledge and Practice among Food Service Workers Operating in Western Romania

The purpose of our study was to determine the knowledge and practices regarding food allergies among food service workers operating in western Romania (Timiş, Arad, and Caraş-Severin counties). A self-administered, multiple-choice questionnaire was completed by 121 Romanian food service workers from 23 food service units from July to September 2016. The food service workers interviewed had a moderate level of knowledge and practices regarding food allergies. The results highlight knowledge gaps in the areas of cross-contact and control of anaphylaxis emergencies, indicating the need to retrain food service workers. Our study revealed positive results according to education level, better practices used by more experienced staff, and differences between job positions and eating places. Higher knowledge levels of trained employees coexisted with better practices reported by employees who attended specific courses on allergens. All of these findings (significant at the 5% level) support the hypothesis that training programs must be adapted to the participants' needs and characteristics (professional experience, field of activity, and food service education level) to be easily accessible and to lower costs.

A systematic review and meta-regression of the knowledge, practices, and training of restaurant and food service personnel toward food allergies and Celiac disease

Background

Up to 3–5% of adults may be affected by food allergies, while approximately 1% are affected by Celiac disease (CD). Food allergy reactions can be severe and potentially fatal, while CD can result in various symptoms. Restaurant and food service establishment staff have an important role in helping to prevent food allergy and CD risks among affected customers.

Objectives

A systematic review was undertaken to identify, characterize, and synthesize published research on the prevalence of food allergy and CD knowledge, practices, and training among restaurant and food service personnel. The population of interest included any personnel in these settings who prepare, handle, or serve food. Outcomes included the prevalence of food allergy and CD knowledge, practices, and training.

Methods

The review was conducted using standardized methods, including: a comprehensive search strategy; relevance screening of abstracts; characterization of relevant articles; data extraction; and risk of bias assessment. Outcomes were stratified into comparable subgroups and descriptively analyzed to examine prevalence trends across studies. Meta-regression was conducted on selected outcomes to identify possible sources of variability in prevalence estimates across studies.

Results

Thirty-eight relevant studies were identified; most were conducted in the United States (50%) and focused on food allergies (90%). Significant variability was identified across studies for most outcomes. Participants generally had a higher knowledge, self-efficacy, and use of practices related to preparing and serving allergen-free meals compared to food allergy emergency response. Participants’ reported use of various risk prevention and response practices was generally low. Most participants across studies had not received prior food allergy training (median prevalence of 65% across 12 studies).

Implications

Key knowledge and practice gaps were identified that could be targeted by future training programs. Research gaps were also identified, including a need for more experimental studies to evaluate food allergy and CD training interventions.

Food Allergy Training for Schools and Restaurants (The Food Allergy Community Program): Protocol to Evaluate the Effectiveness of a Web-Based Program

Background

Food allergy is a growing public health concern. The literature suggests that a significant number of reactions occur in community services, such as schools and restaurants. Therefore, suitable training and education for education and catering professionals using viable and practical tools is needed.

Objective

The objective of this study is to evaluate the effectiveness of a Web-based food allergy training program for professionals working in schools and restaurants, designed to improve knowledge and good practices in the community.

Methods

Free learning programs which contain educational animated videos about food allergy were developed for professionals working at schools and restaurants. The learning programs comprise of nine 5-minute videos, developed in video animation format using GoAnimate, with a total course length of 45-60 minutes. The courses for professionals at both schools and restaurants include contents about food allergy epidemiology, clinical manifestations, diagnosis and treatment, dietary avoidance, emergencies, labelling, and accidental exposure prevention. Additionally, specific topics for work practices at schools and restaurants were provided. Food allergy knowledge survey tools were developed to access the knowledge and management skills about food allergy of school and restaurant staff, at baseline and at the end of the food allergy program. The courses will be provided on the e-learning platform of the University of Porto and professionals from catering and education sectors will be invited to participate.

Results

Data collection will take place between September 2017 and October 2017, corresponding to a 2-month intervention. Final results will be disseminated in scientific journals and presented at national and international conferences.

Conclusions

The Food Allergy Community Program intervention may improve school and restaurant professionals’ commitment and skills to deal with food allergy in the community. Furthermore, this e-intervention program will provide an innovative contribution to understanding the impact of electronic health technologies on the learning process and the development of strategies for community interventions.

Registered Report Identifier

RR1-10.2196/9770

Structural modelling of food allergen knowledge, attitude and practices among consumers in Malaysia

The aim of this study was to assess food allergen knowledge, attitude and self-reported practices among consumers in Malaysia. An online survey was conducted and data were analysed using descriptive statistics and exploratory factor analysis. A model linking food allergen knowledge and attitude and their direct effects on practices were confirmed using structural equation modelling (SEM). Consumers demonstrated moderate food allergen knowledge in this study but scored highly in their attitude towards food allergens. Although participants scored moderately in food allergen knowledge, this does not necessarily translate into practices. There is a possibility that an increase in food allergen knowledge can increase optimistic bias or a sense of over-confidence to manage allergen risks. Consumers' attitude towards food allergens has a positive and significant influence on practices. A positive attitude represents personal beliefs and reflects the level of motivation and care required to manage food allergens effectively. There was insignificant relationship between food allergen knowledge and attitude. This demonstrates a need to tailor targeted risk communication and learning strategies to influence consumers' practices.

Food Allergy Knowledge and Attitudes of Restaurant Managers and Staff: An EHS-Net Study

Dining outside of the home can be difficult for persons with food allergies who must rely on restaurant staff to properly prepare allergen-free meals. The purpose of this study was to understand and identify factors associated with food allergy knowledge and attitudes among restaurant managers, food workers, and servers. This study was conducted by the Environmental Health Specialists Network (EHS-Net), a collaborative forum of federal, state, and local environmental health specialists working to understand the environmental factors associated with food safety issues. EHS-Net personnel collected data from 278 randomly selected restaurants through interviews with restaurant managers, food workers, and servers. Results indicated that managers, food workers, and servers were generally knowledgeable and had positive attitudes about accommodating customers' food allergies. However, we identified important gaps, such as more than 10% of managers and staff believed that a person with a food allergy can safely consume a small amount of that allergen. Managers and staff also had lower confidence in their restaurant's ability to properly respond to a food allergy emergency. The knowledge and attitudes of all groups were higher at restaurants that had a specific person to answer food allergy questions and requests or a plan for answering questions from food allergic customers. However, food allergy training was not associated with knowledge in any of the groups but was associated with manager and server attitudes. Based on these findings, we encourage restaurants to be proactive by training staff about food allergies and creating plans and procedures to reduce the risk of a customer having a food allergic reaction.