Nutrition Connection: Gluten Free Diets, Food Allergies and Food Intolerances• Spring 2008

Every foodservice director has received food requests from both patients and medical professionals for specific food items that the consumer should be avoiding because of an “Allergy To” on their diet order. With one in three Americans currently modifying their diets to avoid a food or food group, this type of request is a growing concern for both kitchens and those who require strict avoidance of food items.

Is it an Allergy, Intolerance, or Preference?

The situation is complicated due to differing uses of the term “food allergy” by lay people versus how it is defined by medical professionals. Frequently the statement given during an initial assessment, “I can’t eat nuts” is communicated to the kitchen as a “nut and peanut allergy,” even though the person may only actually avoid particular types of nuts. This can potentially cause stress when the coconut cheese cake is replaced with pudding, or the pasta with pesto sauce is not served. A common example of the “what the patient requests versus what their diet order states” dilemma includes those who state they are allergic to milk, have it documented in their medical record as a milk allergy, and then request parmesan cheese for their pasta.

In fact, milk tends to be a very troublesome food in the food preference/food intolerance/food allergy determination. Many people simply dislike milk but enjoy cheese, ice cream, and yogurt – clearly a food preference. Others are intolerant to milk to varying degrees and experience intestinal discomfort when too much milk sugar is consumed. Every lactose-intolerant person will have an individual tolerance level that can be confusing for staff.

However, the ranks of those who are truly allergic to milk are growing. A December 12, 2007 news release from Johns Hopkins Children’s Center stated that the accepted belief that 75% of children outgrow a milk allergy by age 3 is no longer true. Their research showed that by age 3 only 20% of milk allergy is outgrown and by 16 years old only 68% outgrow the allergy; for the rest, the milk allergy is expected to continue into adulthood. This means that in the future we will be providing meals for more people who suffer from potentially fatal milk allergy.

The Risks of Misinterpretation

An emerging risk is when a true food allergy is interpreted as a food preference or intolerance. Allergies to common foods such as milk, eggs, soy, and peppers are frequently incorrectly treated as “lactose-free” or “no obvious milk products,” “no eggs at breakfast,” “no tofu,” and “no condiment black pepper” when listed on the allergy section of the diet order – a very risky situation. A person with a true food allergy must follow a strict avoidance diet, including avoiding the allergen when it is an ingredient in other foods, as well as avoiding any cross-contamination during production and plating. In the worst-case situation, ingesting the allergen can lead to anaphylaxis and death. People with life threatening food allergies are understandably very cautious when eating food prepared by others.

Milk allergy needs extra education due to confusing labeling laws that allow foods containing casein (milk protein) to be labeled as “dairy-free.” “Non-dairy” coffee creamers are the best example of this. Eggs are often in baked goods, and soy is a filler commonly found in formed and processed meats. Pepper allergy is growing and refers to the vegetable, which includes paprika but interestingly does not include the black pepper used as a spice.

Complying with the Food Code

In 2005 the FDA was amended to address food allergies. This model food safety guideline recommends that during all hours of operation the person in charge be able to “Describe food identified as major allergens and symptoms that a major food allergy can cause in a sensitive individual who has an allergic reaction.” A free poster can be downloaded at www.foodallergy.org (in the “restaurants” section of the “downloads” page) to help remind staff of the major allergens and to take the food allergy seriously.

Common Food Allergens

In the United States the 8 most common food allergens (referred to as the “Big 8”) are: Wheat, Milk, Eggs, Soy, Peanut, Tree Nut, Fish and Shellfish. Of course, people can also be allergic to items that are not on this list. Over 160 foods have been documented to produce allergic reactions in people.

The Signs of a Food Allergy Reaction

Any of the following symptoms can be a sign of a food allergy reaction in a sensitive individual, and should be immediately brought to the attention of appropriate medical personnel:

• Tingling in the mouth
• Hives, itching, or eczema
• Wheezing, nasal congestion, or trouble breathing
• Abdominal pain, diarrhea, nausea, or vomiting
• Dizziness, lightheadedness, or fainting

The most severe reaction, called anaphylaxis, can rapidly lead to death. With anaphylaxis you may also see one or more of the following life-threatening signs and symptoms:

• Swelling of the lips, face, tongue, or other parts of the body
• Constriction of airways, including a swollen throat or a lump in the throat that makes it difficult to breathe
• Shock, with a severe drop in blood pressure
• Rapid pulse
• Dizziness, lightheadedness, or loss of consciousness

What about Celiac Disease?

Although Celiac Disease is technically not a food allergy, gluten-free diets must be strictly adhered to when used as a therapeutic treatment for Celiac Disease. Essentially, it is treated as a food allergy diet. Celiac is an autoimmune disease where gluten triggers the intestine to damage itself. The damage interferes with food absorption, potentially resulting in weight loss as well as vitamin and mineral deficiencies. Historically Celiac Disease has been one of the most frequently misdiagnosed conditions. Like you, physicians require continuing education, and Celiac Disease is a hot topic – resulting in more diagnosis and therefore more gluten-free diet orders.

How Does Oral Allergy Syndrome Fit in to this Discussion?

Oral Allergy Syndrome is an allergic reaction to certain (usually fresh) foods that develops in hay fever sufferers; the immune system mistakes the food proteins for pollen proteins and causes a reaction. As with food intolerances, the amount of food it takes to trigger a reaction can vary widely. For example, some people can eat three strawberries, but the fourth will give them an itchy mouth. Most sufferers must avoid the food during high pollen season, but many will request this “allergic to” food during the winter.

The most common cross-reactivity between pollens and fruits and vegetables are listed in the table below.

If you are allergic to:	Birch pollen	Ragweed pollen	Grasses	Mugwort pollen
You may have a reaction to:	Apples Peaches Plums Nectarines Cherries Carrots Celery Hazelnuts Almonds Raw potatoes	Melons (watermelon, cantaloupe and honeydew) Bananas Tomatoes	Melons Kiwis Tomatoes	Carrots Celery Spices

 

Managing Food Avoidance Diets in Our Facilities

Education is the key to understanding. Our foodservice employees must be reminded that for some with food allergies, even a small amount can be deadly – so they must always get medical clearance before giving foods listed on an allergy list. The policy must be to initially treat an “allergy to” order as though it is the most severe/restricted version of this allergy, and to continue this interpretation of the food order until it can be individualized and revised (in writing) to better meet that particular person’s needs. It is unfair and unwise to ask kitchen staff to determine if a food is a preference, intolerance, or allergy. The kitchen’s job is to follow the diet order as written; it is nursing’s job to obtain a change to the written diet order if the allergy is not as severe or if it is an intolerance or preference. The facility Dietitian should be consulted on all food allergy diet orders.

CSI fans may remember the episode of the death row inmate whose last supper of a PB&J trumped his death by lethal injection. He obviously neglected to tell the prison about his peanut allergy! With the increase in food hypersensitivity in the population we will see an increase of “allergy to” in foodservice operations. Every patient should be asked about food allergies before their first meal in a facility. If overly restrictive, all changes must be clearly documented to minimize liability.

Preparing to Handle These Special Diet Orders

Foodservice staff should be prepared with the tools to manage the triad of food avoidance: Preference, Intolerance, and Allergy. Success comes from planning, and being prepared for “allergy to” food orders is no exception. Using the HACCP process, the following eight areas are identified as critical to providing safe food to your food-allergic patients: (See Dietary Manager, April 2007 for an in-depth review of the eight points)

1. Create standardized diet orders for special diets
2. Plan menus and appropriate snacks
3. Have appropriate food available and properly stored
4. Ensure tray ticket system reflects the diet order and special handling
5. Hold cross-contamination training for food prep and portioning
6. Establish 100% tray accuracy
7. Train tray delivery and feeding assistants
8. Provide facility-wide training for the food allergy policy

Creating Standardized Diet Orders

To reduce the bickering that occurs when food is denied, include the entire facility on the guidelines of allowed and not-allowed foods. Once written, changes to standardized diet orders can be individualized within the medical chart as the best communication channel for nursing, dietary, and pharmacy.

Here are some sample policies for standardized diet orders:

Standardized Diet Order	Includes All Orders For	Policy
Gluten-Free	Celiac, wheat allergy, wheat-free, no bread	No wheat, rye, barley, or oat ingredients may be used.
Dairy-Free	Milk or dairy allergy, no milk	No lactose, casein, or whey ingredients from cow, sheep, or goat milk.
Lactose-Free	Lactose intolerance, lactose-free, low lactose, milk-free but yogurt okay	Foods may contain casein and/or whey, but may not contain lactose.
Egg-Free	Egg allergy, no eggs	No egg ingredients (including egg substitutes) may be used.
Peanut-Free or Tree Nut-Free	Peanut allergy, nut allergy, tree nut allergy, no nuts	No peanut or tree nut ingredients (including oils) may be used. No coconut or pine nuts
Soy-Free	Soy allergy, no soy	No soy ingredients may be used. However, soy oils and soy lecithin are allowed unless otherwise specified.
Additive-Free	Sulfite-free, MSG-free, nitrate-free, preservatives-free, dye-free Feingold diet	No sulfite, MSG, nitrate, BHT preservatives, yellow #5, or other additive ingredients may be used.
Latex-Free	Any diet, with latex allergy identified in medical chart	Food or utensils may not be handled with latex gloves; no bananas, avocado, kiwi.

 

Following Standardized Diet Orders

Keep in mind that all those on a gluten-free diet will understand that gluten is in wheat, rye, barley, and most commercial oats, but a wheat-allergic person may not understand why he or she has been placed on the more restricted gluten-free diet, and why Rice Puffs and oatmeal are not allowed. Unless marketed as “Gluten-Free,” most wheat-free cereals contain malt, a flavoring usually made from barley. If you look at your cold cereals you will see few options appropriate for gluten-free diets. Foodservice employees are generally taught to use the most restrictive food criteria for safety reasons, and having too many diet orders increases the risk of mistakes. Individualization will have to be done for wheat-free orders. Due to current farming practices, oats are considered contaminated with wheat and avoided unless they are specially grown and tested to be gluten-free.

While some products are specifically advertised as “allergen-free,” many “mainstream” products may be suitable as well. Read the ingredient statements – and then re-read them before use, as manufacturers modify recipes without notice and re-ordered product may have changed. Reinforce that if the safety of a product is unclear you must provide a substitution.

Reading Labels

It is important to read all labels. For example, this kitchen staple contains milk from whey (not the calcium lactate), as well as wheat and soy (Hydrolyzed proteins), and pepper (Paprika).

Label-reading has become easier due to the changes in food labeling laws; the Big 8 are now clearly identified in plain English. This may be in parentheses after the word, such as “whey (milk),” or may appear after the ingredient list with the statement “Contains Milk.” Watch out, also, for “May Contain” statements, as those with particularly severe food allergies may react to foods that have been cross-contaminated at the manufacturer’s site. It is important to note, however, that manufacturers are not required to provide “May Contain” statements. These are voluntary, and the absence of such a statement therefore does not mean that the facility has no other allergens. While all food manufacturers are required to use Good Manufacturing Practices, some people are still more comfortable calling companies to verify that dedicated lines are used.

Ensuring Everyone is Properly Trained

Provide facility-wide training for the food allergy policies with a “no employee left behind” in-service policy. Well-meaning administrators, for example, have been known to deliver trays, ask confused residents if they would like a snack, or offer to get condiments. The patient that has had a wonderful experience with the kitchen and trusts that the facility understands their diet may assume everything offered is as safe as their kitchen-prepared tray. Including food allergy education in new-hire orientations and including the topic in the annual mandatory in-services will help to minimize the risk of harm and chaos when someone is admitted.

Modifying our kitchen in-services to include a sentence on food allergy handling can provide ongoing reinforcement needed for safe food production. For example, the food safety in-service can include temperatures, proper thawing of meats, food cooling, and cross-contact of food allergens. A tray accuracy in-service can easily be freshened up to include how to fix an allergen tray to reduce potential harm (i.e., make a complete new tray, because crumbs and contamination count). Kitchen staff must feel comfortable enforcing the No Food without a Diet Order policy.

For more information on Food Ingredients, download the “How to Read a Label” document on the “downloads” page of the Food Allergy and Anaphylactic Network’s website, www.foodallergy.org, and obtain the Gluten Intolerance Group’s Quick Start Guide at www.gluten.net.

 

By Ronni Alicea, RD