Allergies in restaurants, danger guaranteed. German study

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Food allergies. Prevention, communication, and risk management in restaurants. Widespread illegality, life-threatening for allergy sufferers. A study from the University of Düsseldorf, published 4/24/19 in PLoS ONE, confirms the extreme severity of the phenomenon. (1) An unacceptable public health risk that the European Commission and relevant authorities continue to culpably overlook.

Food allergy in Europe. Prevalence, ignorance and discomfort

The prevalence of food allergy in Europe is estimated to be around 10 percent. (2) Symptoms can be mild (e.g., hives, nausea, dyspnea) but also severe and instantaneous, up to and including leading to anaphylactic shock with life-threatening outcome. Most allergic reactions are found on a limited group of foods including peanuts, milk, eggs, fish and shellfish, wheat, and soy. (3)

Prevention plays a vital role. As there is no cure to date, food allergy sufferers should definitely avoid ingesting allergens. To this end, the European legislature introduced in 2003 a duty to provide specific information on the presence of allergens-even if only in trace, or derived form-on food labels. This duty was extended, in 2011, to all food offered for sale (including bulk and pre-wrapped) and administered by communities. (4)

Ignorance of the rules that have been in place for 16 years exposes allergic consumers to the serious food safety risks these rules are supposed to prevent. As a result, avoiding exposure to allergens is particularly difficult in real life. Particularly when patients cannot exercise direct control over the foods they eat. As is the case in out-of-home food consumption, which accounts for 50 percent, on average, for the European population.

The distress that collective ignorance and social discrimination cause to food allergy sufferers and their parents or ‘caregivers‘ was highlighted in the recent scientific study APPEAL (‘Allergy to Peanuts ImPacting Emotions and Life‘). (5) The research was conducted in 8 European countries with input from national advocacy associations, including Food Allergy Italy, through quantitative analysis of 1836 online interviews with as many peanut-allergic consumers and their family members. 39.9% reported a high level of uncertainty and stress of living with the allergy, with frequent or very frequent levels of frustration in 39.8% of cases, less frequent in 28.2%. 77% experience their diversity in negative terms, 43% have been bullied at least once.

Allergens in restaurants, the University of Düsseldorf study

Food allergy knowledge, attitudes and their determinants among restaurants‘. Researchers from the University of Düsseldorf, between August and October 2017, conducted a survey in 15 districts of the German city (population approx. 640,000). 274 restaurants were randomly selected, with no exclusion criteria for type of cuisine (local, international, ethnic), cost levels, and hours of service. The staff of the venues-295 individuals over 18 years of age, mostly full-time workers (66%) with a waiter’s job description (48%)-were subjected to vis-à-vis interviews. Average age of respondents 37 years, 12 years of work experience in the industry, higher education level (61 percent).

The level of knowledge about food allergies was assessed by asking participants to write down the names of three common food allergens and answer five ‘true/false’ statements:

1) small amounts of allergens can also be consumed by customers with food allergies (false, 82% correct answers),

2) Cooking, frying for example, can prevent food from causing allergies (false, 83% correct answers),

3) A food allergic reaction can cause death (true, 90% aware),

4) Cold water should be administered in case of allergic reaction, to dilute the allergen (false, 65% correct answers),

5) Removing an allergen from a finished dish, removing nuts for example, may be enough to provide a safe meal for allergic customers (false, 82% correct answers).

Only 30% of respondents were able to name 3 food allergens and 41% answered the 5 ‘true/false‘ questions above correctly. In-depth cognitive testing confirmed the serious deficiencies. Although 94 percent of respondents agree that the entire restaurant staff needs to work closely together to meet the needs of allergic customers:

– only 67% of respondents consider that they are responsible in case of allergic reactions of customers at their establishment,
– 41% believe that some food allergies indicated by customers are not true,
– 91% say it is the responsibility of customers to express their food allergy needs,
– 19% would prefer not to serve customers with food allergies.

A food allergy training course was taken by 46% of the staff surveyed. And yet it is surprising how the level of knowledge could not be associated with previous training. Nor was ignorance matched by a desire for more information about food allergies or how to provide safe meals. In Germany, training for restaurant staff and food workers is mandatory before starting work and must be repeated every two years. However, specific references to the topic of allergies are lacking.

Conclusions and reflections. Time for action on food security

Until knowledge gaps and inappropriate behavior [by managers and staff in restaurants, ed.] will persist, it is recommended that individuals with food allergies who eat out [casa] be aware that food allergy knowledge among staff may be lacking. Even when staff seem, or say they are, well informed. It may be helpful in this regard to equip patients with strategies that increase the likelihood that their requests will be properly understood and considered. In addition, patrons with food allergies need to be aware that common allergens are not necessarily indicated on menus (e.g., allergens were indicated in only 28.1% of the restaurants in our study), despite the fact that EU regulations require the indication of common allergens‘. (1)

The study authors point out that ‘every single misunderstanding is a cause for concern among professionals who handle food for an allergic client.’ It is unacceptable to expose allergy sufferers to allergens, and it is even more serious not to know how to assist them following allergic reactions. Because delaying medical treatment can irreparably aggravate the crisis.

Food Allergy Italia – through the voice of its president advocate Marcia Podestà – shares the concerns expressed by the Düsseldorf researchers. ‘This study, unfortunately, is a dramatic snapshot of the reality experienced every day by allergic consumers. Not only in Germany and Italy, but also in other countries in Europe, and around the world. People with severe food allergy can develop, upon contact with the offending allergen, an allergic reaction that can lead to anaphylactic shock and even death. Allergic consumers who eat meals away from home should be able to rely on the competence and rigor of restaurant staff to provide them with accurate information regarding the ingredients contained in the food offered so that they can safely decide what to order. And it is therefore necessary to equip the operator with the necessary knowledge and skills to handle this type of clientele. Training of all food business operators on allergen management should be mandatory and verified. Restaurateurs and their staff need to be sensitized and properly educated to first understand the prevalence and potential severity of this disease. For them to be enabled to sell and serve safe food for the entire population by developing an appropriate allergen management strategy. The European Commission and national health authorities should issue appropriate catering guidelines, monitor their implementation and ensure compliance.’

#DetectiveFood is the bottom-up survey promoted by Food Allergy Italia in collaboration with GIFT (Great Italian Food Trade). We invite all readers to actively participate by following the instructions offered in our previous article.

Thank you!

Dario Dongo

Notes

(1) Adrian Loerbroks, Susanne Julia Tolksdorf, Martin Wagenmann, Helen Smith (2019). ‘Food allergy knowledge, attitudes and their determinants among restaurant staff: A cross- sectional study’. PLoS ONE 14(4): e0214625. https://doi.org/10.1371/journal. pone.0214625

(2) Sicherer SH, Sampson HA (2018). ‘Food allergy: A review and update on epidemiology, pathogenesis, diagnosis, prevention, and management.’ J Allergy Clin Immunol. 2018; 141: 41-58. https://doi.org/10.1016/j. jaci.2017.11.003 PMID: 29157945

Nwaru BI, Hickstein L, Panesar SS, Muraro A, Werfel T, Cardona V, et al. (2014). ‘The epidemiology of food allergy in Europe: a systematic review and meta-analysis‘. Allergy. 2014; 69: 62-75. https://doi.org/10. 1111/all.12305 PMID: 24205824

(3) The National Academies of Sciences, Engineering, and Medicine, Washington DC, USA (2016). ‘The National Academies of Sciences, Engineering, and Medicine. Finding a path to safety in food allergy: assessment of the global burden, causes, prevention, management, and public policy

(4) See dir. 2003/89/EC, repealed by subsequent reg. EU 1169/11. On the responsibilities of food handlers, distributors, and restaurateurs, see articles https://www.greatitalianfoodtrade.it/salute/sicurezza-alimentare-abc-responsabilità-operatori, https://www.greatitalianfoodtrade.it/etichette/le-responsabilità-della-gdo, https://www.greatitalianfoodtrade.it/idee/igiene-nei-ristoranti-l-abc

(5) Montserrat Fernandez Rivas, Helen R. Fisher, Mary Feeney, Frans Timmermans, Lynne Regent, Sabine Schnadt, Marcia Podesta, Angel Sanchez, Pascale Couratier, Betina Hjorth, Fiona Kenna, Ram Patel, Andrea Vereda, Tessa Lush, Katharina Blümchen. (2019). ‘APPEAL (Allergy to Peanuts ImPacting Emotions and Life): Pan-European Results on Peanut Allergy Impact on Allergic Individuals, Parents and Caregivers‘. The Journal of Allergy and Clinical Immunology, Feb. 2019. https://doi.org/10.1016/j.jaci.2018.12.165