When Allergens Attack
Food allergies affect more than 12 million Americans, or 4% of the population, according to The Food Allergy & Anaphylaxis Network (FAAN). Eight foods—milk, eggs, peanuts, tree nuts, wheat, soy, fish and shellfish—account for 90% of all food-allergic reactions in the United States, according to the organization.
FSD talked with operators in two market segments, K-12 schools and college and universities, to find out how they create safe dining environments for customers with food allergies.
K-12 Schools: Developing Policies and Teams to Protect Students
Of the 12 million Americans affected by food allergies, 3 million are children, according to FAAN. For school nutrition directors, working with students who have food allergies is a daily concern.
Jackson-Madison County School System: “We have seen an increase in the number of students with food allergies,” says Susan Johnson, school nutrition supervisor for 13,300-student Jackson-Madison County School System in Tennessee. “I’m not sure if it’s because now they are being properly diagnosed or if there is an
Johnson says the most common food allergy in her district is peanuts, and because of that she has stopped serving peanuts and peanut products. However, if a school has no students who have reported a peanut allergy, the cafeteria manager can purchase peanuts and peanut products to offer on the manager’s choice day.
“We have some schools that have children with severe peanut allergies and we’ve attempted to be peanut free in those schools,” Johnson says. “We’ve asked parents not to send peanut butter.”
When a student with a food allergy enrolls in the district, the school nurse, parents, cafeteria manager and Johnson meet to discuss how to keep the student safe. The group looks over the menus, and the parent circles menu items that may pose a problem with the student’s allergy. Then a substitution can be made. For example, if a soup and cracker entrée is served and the child is allergic to wheat, the parent will circle the crackers, signifying to the cafeteria manager that a different item needs to be substituted for the crackers.
“I have one child who can’t even have eggs that are baked into a product,” she says. “The parent, the cafeteria manager and myself started checking product labels to help the parent be able to mark items that do not have any eggs in them. We make every effort to accommodate.”
Manatee County School District: Much like Johnson, Sandra Ford, director of food and nutrition services at 43,000-student Manatee County School District in Florida, has developed a core team that works with students with food allergies. Recently, however, the district decided it wanted to formalize its
“We have some informal procedures and policies in place,” Ford says. “What we are trying to do is take those and formalize them into a school board policy so that the public can see what our informal measures have been. I don’t think that people realized that we were already going to these measures. It started out as a ‘so what are you doing’ conversation and through the course of the conversation it evolved into ‘we need to make this a school board policy.’”
The current informal policy includes working with the school nurse and parents to find substitutions for students with food allergies.
Ford says the only change in the proposed policy is that students who have a peanut allergy will be able to transfer to a peanut-free school. Under the new policy, the school board would be able to designate up to four schools, one per quadrant, that will be a peanut-free school. In a peanut-free school, no peanut or peanut products would be served in the cafeteria and students, teachers and staff would not be allowed to bring these products into the school.
Ford says the district hopes to approve the policy by the fall.
Right now the district also has one peanut-restricted school, where peanuts are not served in the cafeteria, but peanuts can be brought into the school from students and staff. “The peanut-restricted school doesn’t work well,” Ford admits. “It doesn’t really control the environment of what’s coming into that school. We are trying to get away from that so that the school is either peanut free or not.”
Many schools have some type of peanut allergy policy in place because of the risk of anaphylaxis shock. According to a study published last month in the Journal of Allergy and Clinical Immunology, the cases of peanut allergies in children more than tripled between 1997 and 2008, from 0.4% to 1.4%.
Ford, however, hasn’t seen an increase in the number of students with food allergies.
“You get the feeling that there is an increase because it’s talked about more. When we pull the numbers it isn’t true. Out of the 43,000 students we have, only about 1,100 have some type of allergy. It was surprising to us. That was not nearly the impact that we thought we were dealing with.”
Liberty School District #53: Like Ford, Cindy Hormel, director of food and nutrition services at 11,000-student Liberty School District #53 in Missouri, knows the importance of an allergy policy. In 2008, the district adopted and implemented a comprehensive allergy policy, which outlines what every player, from the parent and student to the foodservice and transportation staff, are responsible for.
For example, the parent is responsible for teaching the child to recognize symptoms of an allergic reaction and how to use an EpiPen. One of the responsibilities of the nutrition services staff is to keep a list of student with food allergies. Each school has a chart in the kitchen with a photo and description of each child with a food allergy in that school.
“We wanted to have continuity within our programs and between the schools in the district to make sure that everyone understands their role in handling students with allergies, especially anaphylactic allergies,” Hormel says. “Before we had the policy in place, everybody was playing a role and everybody was trying to do the right thing, but
it somewhat differed from building to building so we just really felt the need was there to put something into place so that everybody understood the expectation. Also it assisted in putting the parents at ease.”
At the beginning of the school year, letters are sent home to every parent who has a child who attends a school with a student who has a severe food allergy. The letter states that no food can be brought on the bus unless it has been medically documented as a need for a specific child.
Another part of the allergy policy is that every department must have an annual allergy training session. Each department watches an overview video about what food allergies are and then the individual departments address issues specific to the department. For foodservice that training consists of proper procedures for wiping down areas where nuts have been in the kitchen and making food substitutions.
The allergy policy also states how the nutrition services department deals with special food distributions, such as snacks or parties. If there is a student who has a food allergy in the school, the principal can select from a list of snacks that can be served to all students.
“Anything that we provide with peanuts is restricted to the cafeteria so that everything can be properly wiped down,” Hormel says. “We are not a peanut-free school district because we are not a peanut-free world. We also recognize that peanuts are a good source of protein and are something that students like.”
Bloomington District 87 Schools: Connie Mueller, director of food and nutrition at 5,500-student Bloomington District 87 in Illinois, says she has seen an increase in the number of students with food allergies; however, she questions the validity of that increase.
“What I find very interesting is a lot of food allergies are anecdotal,” Mueller says. “I think a lot of parents go to the doctor and say my child is allergic to milk or my child doesn’t like milk and I want you to fill out this form [saying the child has a food allergy].”
In Bloomington, like many other districts, students must bring in a form signed by a physician stating the child has a food allergy before the school will make substitutions.
“There are certainly children who are at risk of anaphylactic shock and very severe allergies, but there are a lot of children that it’s more maybe they are uncomfortable eating something or they don’t like eating something and their parents basically fill out a form and have the doctor sign it,” she says. “I think that’s added to the numbers.
“I had one recently where the child is allergic to milk and dairy products. The child wanted cream cheese for a bagel, and we substituted something else like jelly, and this child was very unhappy. I called and talked to the mom, who said the student can have cream cheese and cheese on pizza. I told her we have to go by what’s on the form.”
Mueller is quick to add that many children in the district do have severe food allergies and the child nutrition department has put procedures in place to keep those students safe. Pre-packaged peanut butter and jelly sandwiches are sold to avoid cross contamination in the kitchen. There are also peanut-free tables in the cafeteria and a separate sanitation bucket for use only on those tables.
Most of the students with food allergies that Mueller works with are in the elementary schools. “At the high school I don’t have one physician’s statement. At the junior high I have eight or 10 and there are 1,200 students. As the kids get older they are able to manage the allergy. But at the grade school they need help, and our grade schools are small enough that my staff knows the kids.
If it’s a severe allergy, we put it in the checkout terminal so it comes up for the cashier to see. It’s another check.”
College and Universities: Developing and Marketing Allergy-Friendly Programs
A9 Allergen Project
Two years ago, the A9 Allergen Project started at 28,000-student University of Colorado at Boulder. Lauren Heising, coordinator for sustainable dining, talks about the program and how signage helps students avoid certain foods.
“I meet with students individually to discuss dietary needs due either to restrictions or personal preferences. We talk about their dietary restrictions, what they typically eat and when, along with likes and dislikes. After I have that information I can more easily help them navigate our dining operations, both all-you-care-to-eat dining centers and grab-and-go locations for the food items and time schedules that meet their needs.
All of our dining centers are all-you-care-to-eat buffets. We utilize menu tagging to inform our customers of allergens. Through our A9 Allergen Project, which started two years ago, we note the top eight food allergens recognized by the FDA (peanuts, tree nuts, fish, shellfish, eggs, soy, dairy and wheat) plus a ninth—gluten—on the menu tags. None of our operations is allergen free. We have all nine allergens within dishes in all operations. That being said, we have brought in several items and delineate areas for customers with food allergens to go. In one of our largest operations, our grill area serves both grilled beef burgers and chicken breast that are marinated and seasoned without the nine allergens we recognize. Customers with wheat and gluten intolerance or allergies need to ask for it without the bun. This past year, one half of a physically divided salad bar was made allergen free, which proved to be very successful. We have brought in gluten- and wheat-free deli turkey and gluten-free pizza crusts. Pizzas are made individually on request. We are very excited about new beef and chicken bases that are wheat and gluten free. All of our peanut butter is in individual pc’s. We also offer rice and soy milk in all operations.
We conduct extensive training for both back-of-the-house and front-of-the-house staff. Our chefs and back-of-the-house preparation staff are trained in how to read ingredient labels, sources of hidden allergens and the implications of ‘adding that something special’ that may have an allergen. Our courtesy workers and staff who prepare the menu tags are trained to work with the chefs and asking the chefs what allergens are in their dishes, along with additional ingredients that may have been added.
Since none of our operations is completely allergen free, we cannot guarantee against cross contamination. We train all of our staff on safe food handling habits and avoiding cross contamination, with special attention to allergens. To avoid cross contamination by customers, we try to put foods with allergens at the end of the serving line. We constantly ask customers through signage and training to use only the utensil for the dish it is designed.”
Keeping in Touch
At 27,000-student Iowa State University in Ames, Jill Arroyo, associate director of residential dining, says the marketing of allergy-friendly dishes starts at orientation and continues on the department’s Web site.
“When students come to campus for orientation, they receive information about ISU Dining. That packet also has information about what to do if that student has a food allergy. When parents and students meet us at orientation, we have our dietitian’s card available to give to the family so they can contact us directly. This is important as it helps the parents know that we’re here to help their student. Students with a food allergy identify themselves and make an appointment with our dietitian. The dietitian sits down with the student and plans his or her menu for the semester. Depending on the severity of the allergy or the availability of food that they can eat off the line we determine whether we need to prepare food for them or if they can just follow the foods that were identified during their initial consultation.
Daily menu information is also available and students can request an ingredient list for anything that we serve. We also offer NetNutrition. This is an online program where students can build their meals and screen for allergens as they look through our menus.
Our allergy-friendly dishes are handled at the Union Drive Marketplace (UDM). It is our largest residential dining center and a very convenient location for most students. The Union Drive has a special team that is assigned with the prep and production for all of the special diets.
All full-time staff and student managers are ServSafe certified, which is unique compared to other venues in the food industry that might only have one or two members who are ServSafe certified. With this our cooks know the hazards of food contamination and dangers of each food allergy.
The UDM is equipped with a separate fridge/freezer for special diets along with cookware, grills and microwaves. We also order specialty items that are inventoried and stored in a separate area than our other dry goods. If the item is something that the student can eat off of the line, the student will let the cook know in the venue and the product will be pulled directly from the oven from a pan that has not been served out yet. Prep for severe allergies is done in a controlled environment by only one or two cooks to prevent cross contamination.”
At 8,000-student Brown University in Providence, R.I., a designated team member makes the allergy-friendly dishes for students to ensure there is no cross contamination, according to Dietitian Gina Guiducci.
“Generally students who require a high level of service and accommodation seek me out to understand what type of arrangement can be made. For the higher level of accommodation for special diets, I meet with each student to understand their diet and level of knowledge around their dietary restrictions; some are newly diagnosed and others have lived with their allergies most of their life. If they are newly diagnosed I will incorporate some education into our meeting. I explain to them what Brown Dining is able to offer them, which is an online ordering system that they access at our Web site. I introduce the students to our production staff so they can become comfortable with who will be preparing their food and so they understand the process of picking up their meals. Students then order their own meals daily, set pick-up times and locations and that's it.
We do not have a separate cooking area in our kitchen. Each day a designated culinarian is assigned to cook special [allergy-free] meals at lunch and dinner. The designated culinarian is required to block out time to stop production in other areas and clean their space in an area that will be free from contamination. They will then be responsible for the prep and cooking of each meal ordered in a safe manner, meaning using clean and sanitized boards, pans, utensils, etc. Once they are done with preparing special meals, they can return to regular production. This system ensures the assigned culinarian is focused and supported for this particular responsibility, and the process stresses that this be done free from distraction. It also enforces the importance to the culinarian the seriousness of what they do for students with allergies. In addition, because students come to the kitchen to get their meals, the culinarians get to see the end result of how what they produced actually makes a huge difference to the lives of these students. They eventually develop a great relationship.”
Working Around Wheat
Operators respond to gluten-free needs, with dedicated menus and stations.
For operators trying to create safe dining environments, wheat can be an area of concern for two different groups of customers. One group is allergic to wheat. Wheat is one of the top eight foods that account for all food-allergic reactions in the United States, according to The Food Allergy & Anaphylaxis Network. Another group has celiac disease, a digestive disease that interferers with the absorption of nutrients from foods. According to the National Digestive Diseases Information Clearinghouse (NDDIC), more than 2 million people in the United States, or about 1 in 133 people, have celiac disease. While celiac disease is not a food allergy—it is an autoimmune disorder—the affects of eating even small traces of gluten can cause damage to the small intestine. Both groups of customers must follow a gluten-free diet to prevent a reaction.
Gluten-free patient menus: “It’s becoming much more prolific,” Jacque Baker, patient service manager for 325-bed St. Clair Hospital in Pittsburgh, says about the number of patients who follow a gluten-free diet.
Because of the increase in the number of patients who cannot eat gluten, St. Clair’s foodservice department, which is managed by Cura Hospitality, developed a gluten-free menu last year. “We’ve seen an increase in the last few years so we decided to come up with a menu specific to [people who follow a gluten-free diet],” says Anne Berzinsky, lead dietitian, R.D., L.D.N. “The idea was to make sure that what we were providing to them was gluten free and also to give them variety.”
“We really wanted to make sure that the gluten-free people didn’t feel like they were singled out just because they have this allergy,” adds Chris Vitsas, general manager.
The gluten-free menu offers patients gluten-free versions of bread, cereal, yogurt and salad dressings. Entrée options include a gluten-free hamburger on a gluten-free bun, gluten-free pizzas and gluten-free baked cod with lemon. There are similarities between the gluten-free menu and the regular menu, such as fresh fruit and vegetables. Some of the gluten-free items are ordered from a manufacturer or specialty store, while others, like the pastas, are made in house.
Vitsas says to ensure there is no cross contamination in the kitchen, separate cutting boards and knives are used to produce items from the gluten-free menu. He adds that because it is a hospital, the staff is used to special diets and allergy concerns, which helps limit cross contamination.
Dining assistants do consultations with patients who follow a gluten-free diet after they are checked into the hospital. The dining assistant visits the patient’s room and goes over the menu with the patient to help him or her select meals that are gluten-free and also meet any other diet criteria the patient might need to follow.
Vitsas says patients are appreciative of having a separate gluten-free menu to select from. “We hade one patient on the gluten-free diet discharged the other day,” he says. “She was getting ready to leave the hospital and she still wanted to talk to me. Most people when they are getting ready to leave are like ‘get away from me, I don’t want to talk to you about food.’ She was so happy with our gluten-free menu that I was able to give her some contact information for a local provider that delivers to homes. I sent her packing with a couple of gluten-free cookies and a brownie to make her day.”
The gluten-free menu has also been beneficial to non-patients as well. “I had a patient whose wife followed a gluten-free diet, and she asked me about guest trays,” Berzinsky says. “She was thrilled that we were able to offer her that gluten-free menu, which made it so much easier for her to be here and not have to go out and try to find appropriate meals for herself while her husband was in the hospital.”
Berzinsky says the most difficult part of developing and maintaining the gluten-free menu is ensuring that items are gluten free. “In general, manufacturers are labeling this better and have that information more at hand. It took some legwork to look at all the labeling and making some phone calls. Staying on top of it is important because manufacturers change how things are prepared, so just because it was gluten free yesterday doesn’t mean they won’t change the way they prepare things and it will continue to be gluten free.”
Right now the gluten-free menu is specific to patients, however, there are some items in the retail operations that are gluten free.
Education and outreach: At 244-bed Pocono Medical Center in East Stroudsburg, Pa., the Metz & Associates foodservice team is using the retail operations as a way to educate customers about gluten-free diets.
In May 2009, during National Celiac Awareness Month, a gluten-free day was held in the hospital’s cafeteria. BK Enterprises, a Philadelphia-based specialty food distributor, brought in several gluten-free items including cookies, muffins and pasta for diners to sample. One of the hospital’s dietitians was also on hand to provide educational materials and answer questions.
Heidi Franssen, foodservice director, says the event started because several of the hospital’s staff had celiac disease or followed a gluten-free diet. “Everyone seems to know someone who has celiac,” Franssen says. “We have a lot of patients with different dietary needs, mostly cardiac and diabetic, but more and more gluten free than in the past.” Franssen says the number of patients with celiac disease has increased because doctors are testing for the disease earlier. “We are stressing education to everyone. It is important for us to meet the needs of everyone in the community, whether they be a patient, visitor or a staff member, whether that is through good food that is diet appropriate or through nutritional education.”
Franssen says the department is working to get information about celiac disease and gluten-free diets in physicians’ offices. “It’s like diabetes. All of a sudden you get that diagnosis and then it’s like ‘what do I have to do differently?’ We want the doctors when they diagnose someone to have the information there and let them know that the cafeteria has stuff available.”
The hospital’s cafeteria offers several gluten-free items, including wraps and breads at the deli, pancake mixes and a gluten-free personal pizza. All of the soup bases are now gluten free. Gluten-free items are designated through signage at the point of sale. The gluten-free items are more expensive, so that cost is passed on to the customer. For example, the gluten-free pizza is $3.95 or $4.25, while the traditional pizza is $2.50.
The department also sells items, such as gluten-free dry pasta, for people to purchase for their personal use.
Cross contamination: For people with celiac disease, even the smallest amount of gluten causes a reaction. To avoid cross contamination, 12,450-student University of New Hampshire in Durham has separate gluten-free zones in each of the campus’s dining halls. The zone has a refrigeration unit, stocked with gluten-free breads, bagels, baguettes, spreads and dressings. On top of the refrigerator, there is counter space with a toaster, bagel cutter and microwave, which are only for use with the gluten-free products.
For gluten-free items that are not found in the gluten-free zone’s refrigerator, the students can use an online ordering system to notify the foodservice staff that they need a gluten-free entrée. Ralph Coughenour, director of culinary services, says they ask students to order using the system at least half an hour before they are coming in to eat. The university makes many items in house that are gluten free such as steak tips, herb-crusted chicken and rice crust pizzas, but the department also orders gluten-free items from manufacturers.
To avoid cross contamination in the kitchen, there is a separate area where gluten-free items are prepared. “We have one convection oven that we never put anything in to bake other than proteins,” Coughenour says. “The baking is done in a separate part of the kitchen. A lot of the gluten-free items are designed just to be sautéed so we don’t have to worry about them being in the oven. When the items go to the dining halls, everything is individually wrapped so nothing can contaminate it.”
America’s pastime: Aramark’s Sports, Entertainment and Conventions division launched a gluten-free line at five of Major League Baseball’s parks this season. The effort began last year at Coors Field in Denver, with what Aramark believes is the first dedicated gluten-free concessions stand in a baseball park. The stand sells gluten-free hot dogs, hamburgers, chicken sandwiches, potato chips, cookies, brownies and beer.
“We pride ourselves in designing menus that reflect the tastes and flavors of our guests, and the growing selection of gluten-free food on today’s menus is the result of fans with celiac disease suggesting we further diversity our menus,” says Marc Bruno, president, Aramark Sports, Entertainment and Conventions. “We understand that food is an integral part of the baseball experience, and we want to ensure that everyone who attends a game is able to enjoy this important feature of the ballpark experience.”