What Foodservice Staff Should Know About Food Allergies
By Debra Indorato, RD, LDN
Today’s Dietitian
Vol. 7 No. 8 P. 38

Foodservice staff are usually the anonymous preparers and servers of food. But they need to step up to the plate when it comes to knowing about food allergies.

Patient satisfaction is more than keeping patients happy with great food and excellent service. Meeting their needs is an integral part of providing customer service that meets and exceeds patient expectations. These needs often require much more than accommodating food preferences, prescribed diets, and meeting specific nutrient needs.

Accommodating food sensitivity and intolerances is important to the patient, but even more important to the foodservice department managers and staff.

During a hospital stay, patients want to be assured that the medical professionals caring for them know everything. They provide the staff with information on allergies when the admission history is completed. It is the responsibility of those reviewing this information to communicate specific dietary issues such as food allergies and intolerances to the foodservice department.

Patient services managers and dietitians are often called to speak with upset patients who are allergic to a food they’ve received on their tray several times. They can’t understand why they received eggs when they told the nurse they were allergic to eggs. It is assumed that the foodservice staff knows about the allergy because that information was provided at admission.

Many times that information is communicated, entered into the system with the diet orders and preferences, and printed on a tray ticket. A foodservice worker may interpret allergic to eggs means no eggs at breakfast or allergic to milk means no fluid milk when all milk products must be avoided. Foodservice staff may not know that the patient who needs to avoid egg needs to avoid mayonnaise, French toast, pancakes, lemon meringue pie, and many other foods that contain egg protein. As dietitians, most of us are knowledgeable of the intolerance mechanism and have access to books, diet manuals, and other resources that outline foods to include, foods to avoid, and what to look for on a food label. In the hospital setting, the foodservice staff purchasing, preparing, and serving patients must be as knowledgeable or perhaps more knowledgeable of food ingredients and preparation methods to avoid triggering allergic reactions in patients. Hospitalized patients are often scared and want to feel safe. Patients who have had significant reactions know what to avoid but unfortunately do not know what they’re receiving on their tray. They can avoid some allergens by simply avoiding the obvious trigger foods on the menu, but what about those hidden ingredients or the cook who continuously wipes his or her hands on an apron laden with every food he or she prepared in a day?

Training Matters
A training program for foodservice workers that includes food sensitivity and intolerance should include all members of the department. Patients (or customers) should be able to approach anyone in the department with questions about the menu, how foods are prepared, the ingredients, and what brands are used. Is this a safety issue? Most definitely.

Allergies and intolerances trigger an array of symptoms that can involve one or more body systems. Symptoms can range from mild and subtle to severe and obvious. Allergic reactions can be fatal. For most adults, peanuts, nuts, fish, shellfish, and sulfites are the top offenders. Children tend to have allergies to milk, eggs, peanuts, soy, and wheat.
Foodservice staff is trained in food safety and depending on the area may be required by the local department of health to maintain a food handler’s card and attend regular classes to maintain the card. Safe food handling practices learned in the classes and practiced diligently will help prevent cross-contamination of foods with allergens meant to be avoided.

What should a good training program on food allergy for foodservice workers include? All foodservice staff should be trained whether they work the back of the house or the front of the house. They need to be trained to listen carefully when a patient or customer says they’re allergic to something. A highly effective server should know not to offer the apple crisp with crumb topping containing ground nuts to someone who asked about peanut in the Thai noodles.

Training may require more than one session, as there is a lot of information to present. Initially staff need to understand and be able to differentiate between an adverse reaction to food, food intolerance, and food hypersensitivity (allergy). They also need to understand how a diagnosis is made, what symptoms may occur, and that there is no cure for food allergy. The only way to avoid a reaction is to avoid the trigger food. That is where foodservice staff can be useful—helping the patient avoid the food allergen. Knowledge of ingredients and careful label reading will help limit reactions. Just as important is knowledge of preparation methods and utensil use. Different cutting boards should be used and each item to be served should have its own utensil. Nursing and other patient care staff members involved in feeding patients also need to be trained. They need to double check the diet order, allergy information, and communicate all the allergy information for the menu to be adjusted. Washing hands is important for patient care staff on the units, especially after they’ve eaten their own meals. Food residue on the hands can easily be transferred to the patient or something the patient will touch.

Hospitality associates need to know what to do should a patient have a reaction while they are in the room. Anne Munoz-Furlong, founder and CEO of The Food Allergy & Anaphylaxis Network (FAAN), a nonprofit organization helping professionals and the public by increasing the awareness of food allergy and providing educational programs and materials, was quoted in Restaurants USA, saying, “If we could get chefs to understand, it would make a world of difference. Unfortunately, questioning customers are often perceived to be hypochondriacs.”

Potential for Reactions
Cafeteria staff and waitstaff need to know what to do if a customer has a reaction while dining. Choosing a food in a cafeteria can be a life-or-death matter for someone with a severe sensitivity. Even the smell of a food cooking can trigger a reaction. There have been news reports of customers having fatal reactions when a waiter walked by the customer with a plate of steaming shrimp, or nuts that were in a crumb topping or graham cracker crust. Informing staff of the potential of fatalities should heighten awareness of foods, food ingredients, food preparation, and food handling as part of the food safety program. Staff needs to know where ingredients can be hidden, especially when partially prepared foods are purchased for saving time in the kitchen. If you walked into your kitchen today, would your foodservice staff know that nuts can be hidden in pie crusts, gravies, chili, spaghetti sauce, soups, brownies, and Chinese and Thai foods?

Staff should be trained to know about ingredients and fully describe the item and its preparation upon request. They should be honest with the patient or customer if they do not know the ingredients and then find out. Patients or customers may want to see the labels themselves. Good relationships with approved vendors will enable obtaining accurate and adequate information in a timely manner.

Label Reading
The FAAN (www.foodallergy.org) offers a variety of educational materials, including training programs for school foodservice. The information in the kit can easily be adapted to other foodservice operations. FAAN also has a How To Read A Label guide that lists the common allergens and ingredients to avoid. The How To Read A Label cards are available as refrigerator magnets that can be placed in all production areas. It may be wise to have one person on each shift designated as the person to check ingredients, speak to the patient or customer, oversee preparation of the food, and do the final check before the food is served. Prior to each meal, the designated person should review all the food items to be served with the staff indicating the major food allergens that may be found in each food on the daily menu. Because a product was safe and allergen-free in the past does not mean it still is. Read labels carefully each time a product is used. Devising a coding method for labeling allergens or using a solid color tray mat may be beneficial in alerting anyone serving the patient to pay attention to all the details.

Sharing recipe information with the customer may help to assure them that they will not receive the food that causes a problem for them.

Production staff should be educated to communicate when substitute ingredients are used. This will enable time to adjust the menu and notify the patient of the substitution, letting them pick an alternate item if necessary.

Cross-Contamination
Because certain allergenic proteins can leach into foods, foods served should not come in contact with allergenic foods. Cross-contamination occurs when a food comes into contact with another food and their proteins mix. As a result, each food contains small amounts of the other food that are often invisible to the chef or consumer. For persons with severe food allergies, even a miniscule amount can cause a reaction. In manufacturing, many products are run on the same line, which can result in contamination. Many manufacturers are now taking precautions to prevent this by running products containing allergens last or on a separate line.

Using the same frying oil, a common practice, is an easy way to cross-contaminate. When fish is fried in oil, it releases some of its proteins. If another food, such as french fries or a chicken patty, is cooked in the same oil, it will pick up the fish protein. In this case, the fish allergic person eating the fries may have a reaction thinking it is the fries rather than the fish that caused the reaction.

Other reasons for cross-contamination include inadequate cleaning of shared equipment, using the same cutting boards repeatedly without proper cleaning and sanitizing, using the same serving utensil for more than one item, spillage and leakage during storage, mistakes, foods touching each other in storage, splatter from steam or oils, and just wiping off a table without properly cleaning and sanitizing.

Although tempting, staff should not wipe hands on aprons, and cloths used in the kitchen should be changed frequently. Kitchens with the luxury of space can have an area designated as allergen-free for preparation, which is especially helpful in a children’s hospital since children have a high incidence of food allergy.

Attempting to remove allergenic foods from a food such as removing the cheese from a cheeseburger in a milk-allergic patient is not acceptable. In this case, the meat would still be contaminated with the allergen. Sauces, gravies, and dressings should be served on the side.

Proper cleaning of equipment is imperative. Methods of cleaning should be reviewed with all employees, not only the pot washer or dishwasher. Foodservice staff should know where to locate all manuals for equipment in case they need to refer to diagrams for removal of parts for cleaning. Hand washing is essential. If gloves are worn, use nonlatex gloves. Oral allergy syndrome is a sensitivity to certain foods that also cross-react with latex. Some hospitals have policies against the use of latex gloves or avoidance of certain fruits and vegetables for latex-allergic patients.

Have the emergency department number posted in the kitchen and cafeteria, especially next to the phone. Numbers for anyone else who needs to be notified should also be posted. Emergency situations can be prevented if everyone is careful and communicates effectively.

Patients and customers should be encouraged to ask questions and make special requests ahead of time to allow adequate time for preparation. Mistakes are often made when rushed preparation occurs.

Working together as a team, knowledge about food ingredients and preparation, effective communication, maintaining a clean, organized kitchen, using proper storage techniques, and paying detailed attention to the patient or customer will help prevent the occurrence of reactions and fatalities. Train, train, and train your staff in food allergy awareness.

— Debra Indorato, RD, LDN, is a patient services manager with Morrison Management Specialists and owner of Approach Nutrition and Fitness, a private practice in Chesapeake, Va.

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