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Weekly UpdatesGiven the potential severity of allergic reactions to certain foods, restaurant operators and staff need to know how to prevent guests from eating what could be fatal food. When the state of New Jersey enacted a law to create a fact sheet to explain safe handling of food allergens, a research team examined the information and communication challenges regarding food allergens-including knowing what foods cause the most trouble and how to avoid cross-contamination. The team then created a fact sheet that depicts the suspect foods and explains specifically how to avoid triggering food allergies in guests. This fact sheet will be displayed in all restaurants in the state.
Keywords: food allergies; New Jersey restaurants; restaurant management
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Food allergies are a common, serious, and sometimes fatal problem. Nearly 11 million Americans have food allergies, comprising an estimated 6 to 8 percent of young children and 4 percent of the general population (Food Allergy Training Guide 2006; Answers to Frequently Asked Questions 2002; Sampson 2004). Moreover, the prevalence of food allergies appears to be on the rise. Between 1997 and 2002, the number of children with peanut allergies nearly doubled (Sicherer, Munoz-Furlong, and Sampson 2003). While most food allergies are mild and cause minor symptoms, such as sneezing, itching, or digestive upsets, some allergic reactions are far more serious anaphylactic reactions. For those who are severely allergic, exposure to a food allergen, even a trace amount, may cause an asthma attack or swelling of the tongue, lips, or throat that can lead to asphyxiation. In fact, it is estimated that such anaphylactic reactions occur in 29,000 Americans annually and result in 150 to 200 deaths (Board of Directors, American Academy of Allergy, Asthma and Immunology 1998; Sicherer, Munoz-Furlong, and Sampson 2001). Although any food can cause an allergic reaction, eight foods account for 90 percent of all food-based allergic reactions. Those are peanuts, tree nuts (e.g., walnuts and cashews), milk, eggs, fish, shellfish, soy, and wheat (Basset 2005). Peanuts, tree nuts, and shellfish are the most likely to cause anaphylaxis. The only known way to prevent allergic reactions caused by trigger foods is to avoid those foods (Sicherer and Sampson 2006; Sampson 2004). For the person with food allergies, that means reading ingredient labels on food packages and finding out how foods are prepared in restaurants and what ingredients are used. To correctly answer guests' questions in this regard, all food-service personnel, from those at the corner ice cream or hot dog stand to the largest institutional cafeteria, need to be fully informed about their establishment's menu ingredients, preparation procedures, and storage procedures. With the increasing prevalence of food allergies, it will become ever more important for food-service personnel to know how to safely serve a customer with food allergies.
Ensuring allergen-free food seems to be in question. A recent study of sixty-two food-service operations found that when peanut-free meals were prepared shortly after a meal containing peanuts, 21 percent of the supposedly peanut-free meals actually were contaminated with peanut protein. Furthermore, in 11 percent of these contaminated orders, food-service personnel reassured patrons that the meal being served was peanut-free (Leitch, Walker, and Davey 2005).
These data highlight the risk to patrons with food allergies and the importance of educating the food-service industry about food allergies and how to safely prepare and handle allergen-free orders. The state of New Jersey recognized this need with its January 2005 passage of Public Law 2005, c.206 (A303 ACS 2R), which mandated the development of a fact sheet designed to help food-service personnel safely handle food orders of customers with food allergies. Prompted by the legislation, the study described here sought to determine how food-service operations in New Jersey handle requests for allergen-free orders and to identify what food-service personnel need to know to better serve customers. We used this information to create a fact sheet for the industry. In this regard, we see no reason that restaurants in New Jersey should not be representative of all restaurants in the United States, and perhaps beyond. (This study was approved by the authors' institutional review board.)
Procedure
We established a twenty-five-person advisory panel to guide the development of the fact sheet and ensure that it was complete, accurate, and appropriate to the target audience's needs. This panel included health professionals (i.e., registered dietitians; physicians, including an allergist and a pediatrician; local health officers; registered environmental health specialists; and a school nurse), food-service experts (i.e., school food-service administrators and restaurateurs), allergy education experts (i.e., Food Allergy and Anaphylaxis Network, Cooperative Extension educators), and food-policy experts. The development of the fact sheet followed a fivestage process.
Stage 1: Review of existing literature. In the initial stage, the researchers conducted an extensive literature and internet search to identify existing food-allergen fact sheets designed for food-service operations. Meeting in small focus groups led by a trained moderator, advisory panel members reviewed and reacted to the content, graphic style, and presentation for each of these fact sheets. Their comments guided the development of the new fact sheet as well as the moderator's guide for the baseline interviews with food-service personnel.
Stage 2: Baseline interviews. In this stage, individual thirty-minute interviews or small focus-group sessions were conducted with food-service managers from institutional food-service, catering, fine-dining, and quickservice establishments throughout New Jersey (for a discussion of focus-group and interview technique, see Butler, Dephelps, and Howell 1995; McLafferty 2004; Britten 1995). The interview moderator's guide developed for this stage was based on questionnaires measuring food-allergy training, readiness, and health-related quality of life, as well as the aforementioned input from the advisory panel (for example, see Food Allergy Training Guide 2006; Marklund, Ahlstedt, and Nordstrom 2004; Rhim and McMorris 2001). The questions were designed to determine (1) how food-service operations currently handle requests from customers with food allergies; (2) the comparative importance that food-service personnel place on knowing about how to prevent food-related allergic reactions in customers in comparison to everything else they need to know; (3) what food-service personnel need to know about food allergies to improve service; (4) barriers to receiving and accepting education on how to prevent triggering a food-related allergic reaction; and (5) how food-service personnel prefer food-allergy messages to be delivered, including format (e.g., posters, electronic means), layout (e.g., size, graphics), tone (i.e., positive or negative), and language (e.g., English, Spanish).
Baseline participants were recruited by e-mail, phone, or personal reference to participate. All interviews, which were confidential, were conducted by a trained moderator. In addition, a trained researcher attended each session to take comprehensive notes, which were transcribed within twenty-four hours. The transcribed notes were reviewed for thoroughness by the moderator and for clarity by a second researcher who was not present at the interview, and any discrepancies or ambiguities were resolved.
Another member of the research team, who is trained in interview data-analysis procedures, analyzed the completed interview notes to identify and classify the key points from each interview. This classification was reviewed by yet another member of the research team for clarity and to achieve unanimous agreement. Finally, the data were combined to create a synthesis of the baseline interview findings.
Stage 3: Development of food-allergy fact sheet. The research team used the interview data and advisory panel input to draft the text for the fact sheet and to guide the graphic artist. To help overcome the literacy and language barriers identified by interview participants, researchers drafted the fact sheet in simple language and translated the content into Spanish (see Mayer and Rushton 2002; Miller 2001). In addition to the text, the development guide suggested appropriate photographs, tone, and size for the fact sheet. The graphic designer drafted two fact sheets with different layouts (see Exhibit 1). These fact sheets were analyzed in the follow-up interviews.
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Stage 4: Follow-up interviews. Using a follow-up interview guide, researchers asked food-service managers in various foodservice establishments in New Jersey to assess the readability, relevance, usefulness, and completeness of the content, as well as to choose between the two fact sheet designs. Food-service personnel were asked for their assessment of the fact sheets, using the same procedures as for baseline interviews.
In addition to gathering input from foodservice managers and workers, we also asked the advisory panel members for their analysis of the two draft fact sheets. Next, a summary of the content and design review from food-service managers and owners was presented to the advisory group, which offered final suggestions for content and design revisions.
Stage 5: Final fact sheet. The follow-up interview data and advisory panel input were summarized. The final content and design refinements were shared with the graphic designer to guide the creation of the final fact sheet.
Results
The review of existing literature located only eleven allergen fact sheets directed to food-service operators--and most of those originated outside the United States. The advisory panel and research team judged that none of the eleven sheets contained sufficient information to enable food-service personnel at any level to safely handle requests from patrons with food allergies. The advisory panel proposed that the fact sheets should do the following: (1) convey the seriousness of food allergies; (2) provide step-by-step food-handling instructions on how to prevent a food allergic reaction; and (3) educate food-service employees never to guess whether a food is safe for a customer, but instead to ascertain the ingredients and preparation. The panel recommended that the fact sheet contain pictures, symbols, or graphs to help convey the messages and be written in both English and Spanish.
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