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According to the British Nutrition Foundation, food intolerance is the 'general term used to describe a range of adverse responses to food including allergic reactions. Adverse reactions result from enzyme deficiencies, pharmacological reactions, and other non-defined responses. An allergic reaction to a food can be described as an inappropriate reaction by the body's immune system to the ingestion of a food (www.nutrition.org.uk 2009).
Nuts are one of the most common causes of food allergies in the world. (Metcalfe, 2001, pg. 890). As there are over a hundred varieties of nuts it is unclear if all can cause an allergic reaction. However if you have a nut allergy, it is most probable that you react to peanuts or tree nuts (Hourihane, 2002, pg. 39). Tree nuts include almonds, pecans, walnuts, hazelnuts and cashews. Peanuts are commonly known as groundnuts or monkey nuts but have a variety of different names in a variety of languages (see appendix 1). They are not actually nuts but come from the leguminosae plant family. This family contains over 30 different species of plant. Abbreviated to legumes, peas, beans, lentils, soya beans, carob and liquorice all come from the same plant species; unlike tree nuts, legumes grow underground (Pescatore, 2003, pg. 142).
It is possible to develop an allergy to nuts at any age. The number of people affected by peanut allergies has increased dramatically since the 1970's and now affect up to one third of the population in industrialised countries (Wright 2001). Research provided by the University Hospital of South Manchester (no date) states that about 1 in 200 children (0.5%) have a reaction to peanuts by the age of five years.
It is not known exactly how many people in the UK have a food allergy. Population studies in the UK suggest that between 1 and 2 people in 100 (1-2%) have a food allergy that can be diagnosed reproducibly, whereas as many as 30 in 100 (20-30%) believe themselves to be allergic or intolerant to one or more foods (Nutrition.org.uk 2009). According to Patient.co.uk (no date) about 1 in 200 in the UK (0.5%) people has an allergy to tree nuts. A report from the USA has found that 5% of children studied who had a reaction to one legume had symptoms with other legumes (Wright 2001). This suggests the idea that legumes are a common cause of allergy. Further to this, according to the American Academy of Allergy, Asthma and Immunology, peanut allergies in children have 'increased twofold from 1997 to 2002' (Lalanilla, 2005). This shows the numbers of people with peanut allergies are continuously growing.
There is no consensus view at present for why some people develop an allergic reaction for nuts and others don't. One interesting view is given by McEwen (1996) who studied patients with and without nut allergies and found children who were given nut based or whole nut products from a young age were more likely to develop an allergic reaction to them in later, or adolescent life.
Nut allergies were once considered to be a life-long condition and it is thought 80% of children with peanut allergy under 5 years of age, will have the allergy into later childhood.
An allergic reaction can be caused by many different factors. According to Roux, Sathe and Sharma (2009, pg. 69) the most common factor is consumption (88%), followed by skin contact (9%) and finally airborne exposure (3%). Airborne exposure involves cross-contamination through the transfer of nut partials from one product to another or inhaling in the allergens from the dust used in the preparation of nut based products.
There are many different ways in which nut allergies affect people. It is almost always an immediate reaction however the severity of the reaction may differ between sufferers. The most common reactions include a rash, tingling sensation around mouth and lips, itchy skin, breathlessness, vomiting and stomach cramps (Escott-Stump, 2008, pg. 118). More serious reactions include swelling of the tongue, dizziness, swelling of the face and lips and constriction of the throat resulting in difficulty in breathing.
In the more extreme cases of allergic reactions, the person may suffer from anaphylaxis shock. This is when the airways from the lungs become constrict making breathing difficult. Through the examination of patients who have an allergic reaction there is likely to also be an increase in heart rate and a drop in blood pressure causing the patient to become unconscious or even death (Carpenito-Moyet, 2008, pg. 872). Due to the severity of the reactions caused by allergies, this creates a problem when dealing with restaurants and kitchens who serve food to peanut allergic customers.
People who suffer from severe allergic reaction which has the potential to cause anaphylaxis, may be prescribed adrenaline (Chapel, Haeney, Misbah and Snowden, 1999, pg. 87). Adrenaline is a hormone which is a chemical naturally found in the body that relaxes all muscles, helping to reduce any swelling and make breathing easier. As allergic reactions are mostly immediately after exposure, many suffers will carry a single dose of adrenaline in the form of an EpiPen (Muñoz-Furlong and Sampson, 2003, pg. 412). This is a syringe full of adrenaline that can be used in a matter of seconds with the potential to save the sufferers life. Sufferers may also wear or hold some form of medical identification. I would recommend a bracelet or a credit sized card to be kept in a wallet or purse. The information held on these items should consist of details of the allergy and an emergency contact number.
This highlights a dilemma within the hospitality environment. If a customer appears to have an allergic reaction, should one of the staff members assist and administer the EpiPen for them and what happens if they administer this wrong? As there has not yet been a case it is unclear whether the employee or establishment would be prosecuted. Another example is if the customer was having a heart attack instead of an allergic reaction (there are similar symptoms) and an EpiPen is administered, this has the potential to cause serious harm (Hearnes, 2003, pg. 177). As mentioned above it is unclear to what the rules and regulations around such circumstances are but brings to life the enormity of the situation and the need to ensure the hospitality industry is well trained and equipped in dealing with these life threatening allergies.
It is also vitally important for nut allergy sufferers to check the packaging of food carefully to ensure it does not contain nuts. In 2005 a legislation was introduced which required for all pre-packed food sold in the UK and EU to state on the label whether the ingredients contain nuts (Food Standards Agency, no date). One of the biggest dilemmas for sufferers of nut allergies is although food may not contain nuts it may have been produced in a kitchen or factory which may have traces of nuts during other productions. Usually the label will state 'may contain nut traces'. Many of the leading brands will state this on their products although this is not a legal requirement in the United Kingdom. It is important to understand that allergens in nuts and peanuts are not destroyed when heated at high temperatures. Lawley et al (2008) argues roasting peanuts may actually increase their allergenicties.
Something as simple as a plane journey may seem like routine to many but for allergy sufferers it provides a risk to an allergic reaction. Although there is no factual evidence, it is argued that sufferers are more likely to sufferer an allergic reaction whilst travelling by plane than any other mode of transport. The most likely cause of a reaction on a plane would be someone on board eating nuts or eating a meal that has been produced near nuts (Freund and Rejaunier, 2003, pg. 179). Many sufferers will take precautions and order special meals before the flight, or even choosing to take their own meal. Unfortunately someone on board could have been eating nuts, which in extreme circumstances can cause a reaction. This could be through passengers touching surfaces on the plane and leaving allergens behind. (Freund and Rejaunier, 2003, pg. 179) Due to this risk the airline may arrange for nuts not to be served on the flight. Many airlines will not offer nut free flights but only offer nut free food. For example Singapore Airlines (www.singaporair.com) will offer a nut free alternative to the in-flight meal but will not offer a 'nut free flight' as many of the dishes served on board contain nuts and they are not able to control what food other passengers may take on board.
It is also important for nut allergy suffers to be careful when eating out. To avoid complications it is important to know what the restaurant serves and the style of cooking they use. I would also advise sufferers to visit the same restaurants regularly as so the establishments get to know them and become familiar with their needs. The time you book a table may seem of small significance but this could help with ensuring all dishes are prepared to the correct specifications, as during busy periods a peanut sufferers needs may be unintentionally overlooked. By providing the chef written guidelines in advance about certain needs this can reduce the risk of an allergic reaction. I would advise the sufferer to take a copy every time they eat out. As well as giving written guidelines it may also be beneficial to telephone ahead giving the chef time to prepare a separate meal in advance.
It is important to understand that although allergy sufferers have grown dramatically over the past forty years there are no set guidelines from the government on how an establishment should accommodate an allergy sufferers needs. Under Section 14 of the Food Safety Act 1990 (Appendix 2) businesses must not 'sell to the purchaser's prejudice any food which is not of the nature, substance or quality demanded by the purchaser' and under Section 15 of the same act, businesses must not falsely describe or present food (Office of Public Sector Information, 2009). This means that businesses must provide food that is fit for consumption and in accordance to the customer's expectations.
One of the biggest tribulations in a kitchen is the possibility of cross-contamination. This is when allergens are transferred from one food or food ingredients to another (Trickett, 2001, pg. 20). This would result in previously safe food becoming harmful. The enormity of the situation only becomes apparent when you take into consideration factors such as utensils and work surfaces in a kitchen which may have at some point come into contact with peanuts, as well as containers which are hard to clean, ovens with burnt on food which had leaked out of dishes, cooking oils used during the cooking stage but also which have been used by the manufacture to make the product to be sold to the kitchens as well as flour.
I believe the kitchen will have to use common sense when dealing with peanut allergic customers and may follow some of these procedures, If they think the controls put in place to minimise the risk of cross-contamination are not going to be effective enough for a person with a severe food allergy, they must ensure this is communicated to the customer. They may consider putting up a notice inviting customers to talk to staff about their specific needs. Cateringforallergy.org.uk (no date) offer useful tips for kitchen staff to follow such as;
- If you offer nut-free alternatives, prepare them first and pre-wrap them for additional precaution.
- Always clean the work area, utensils, hands, and possibly aprons after handling key allergens and before preparing other foods, which don't contain them. Soap and hot water have been shown to be the most effective in removing allergen traces.
- Keep certain preparations areas nut-free
- Never use major allergens as casual substitutions for a given dish (e.g. do not replace olive oil with walnut oil in your salad dressings)
- Don't let nuts touch food that do not have those ingredients
- Think before cooking with oils that have been used to cook other foods
For further information see Appendix 3.
There has been no legislation passed to say that a restaurant cannot refuse a customer who suffers from an allergy and therefore there is little mentioned on this topic. It would seem common sense that if an establishment did not feel they could competently serve a guest with a peanut allergy then they should not. A recommendation would be to bring in an allergy safety team to inspect premises ensuring that all establishments can cater for such needs, whilst being able to train and answer questions onsite. A scheme has been launched in Wales (Worsfold, 2008) where establishments will be inspected on how safe they are for allergen customers just like when they are inspected by food safety officers (Appendix 4).
It is apparent most confusion comes down to a lack of training in such industries. Recommendations would suggest such criteria as who should be trained, what sort of training, and the cost of training and a set of guidelines from the government would need to be outlined. There are many pilot schemes which are trialing the most effective way of making companies more aware of this topic but at present there is no consensus. I think there should be one person from front of house and one from back of house at all times who are trained in dealing with peanut allergies and how to deal with diagnosing and treating an allergic reaction. I think the training should be included in the food hygiene course. A weakness of this is cost. For large establishments it would be costly to train all employees but would be feasible. However for smaller and independent establishments, they may not have access to the finances in order to pay for training.
It has become apparent from all the above research, sources and information provided (mostly internet sources as to keep up to date with the latest developments and news) to the general public there is still very little know about peanut allergies. It seems apparent that all the research around this topic has been focused on how to deal with someone who has an allergic reaction rather than preventing it in the first place. The North Carolina Agricultural and Technical State University announced in 2007 that one scientist, Dr. Mohamed Ahmedna, had developed a process to make allergen-free peanuts. Primary tests produced a deactivation of peanut allergens in roasted kernels (Science Daily, 2007). The process is still yet to be commercially used whilst more studies are undertaken. In conclusion I feel that there needs to be a greater emphasis on the prevention of an allergic reaction. There is a gap in the training procedures within establishments which I think the above recommendations should be taken into account.
- British Nutrition Foundation (no date) What is Food Allergy and Intolerance? Retrieved on 10th November 2009 from the World Wide Web: http://www.nutrition.org.uk/nutritionscience/allergy/what-is-food-allergy-and-intolerance
- Carpenito-Moyet, L. J. (2007) Nursing Diagnosis: Application to Clinical Practice, 12th edn, Philadelphia: Lippincott Williams & Wilkins.
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- Chapel, H., Mansel, H., Misbeth, S. and Snowdon, N. (1999) Essentials of Clinical Immunology, 4th edn, Oxford: Blackwell Publishing Ltd.
- Escott-Stump, S. (2008) Nutrition and Diagnosis Related Care, 6th edn, Philadelphia: Lippincott Williams & Wilkins.
- Freund, L. H. and Rejaunier, J. (2003) The Complete Idiots Guide to Food Allergies, Indianopolis: Alphabooks.
- Hearn, S. (2003) Remote Medical Emergencies, in: Anderson, S. and Warrell, D. (ed.) Royal Geographical Society: Expedition Medicine with the Institute of British Geographers, Florida: Taylor and Francis Group, pg. 171 - 181.
- Hourihane, J. (2002) Peanut and Treenut Allergy: Why so scary, in: Emerton, V. (ed.) Food Allergy and Intolerance: Current issues and concerns, Leatherhead: Leatherhead Publishing, pg. 39 - 50.
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- Metcalfe, D. D., Sampson, H. A. and Ronald, S. A. (2003) Food Allergy, Adversary Actions to Food and Food Additives, in: Munoz-Furlong, A. and Sampson, H. A. (ed.) Management of Food Allergy, Oxford: Blackwell Publishing Ltd, pg. 408 - 425.
- No Author (no date) The Food Safety Act 1990, Retrieved on 15th November 2009 from the World Wide Web: http://search.opsi.gov.uk/search?q=section+14+of+the+Food+Safety+Act+1990&btnG=Search&output=xml_no_dtd&client=opsisearch_semaphore&proxystylesheet=opsisearch_semaphore&site=opsi_collection
- Patient UK (No date) Nut Allergy, Retrieved on 12th November 2009 from the World Wide Web: http://www.patient.co.uk/health/Nut-Allergy.htm
- Pescatore, F. (2003) The Allergy and Asthma Core, New Jersey: John Wiley and Sons, Inc.
- Roux, K. H., Sharma, G. M. and Sathe, S. K. (2009) Tree Nut Allergens, in: Alasalvar, C. and Shahidi, F. (ed.) Tree Nut: Composition, Phytochemicals, and Health Effects, Florida: Taylor and Francis Group, pg. 69 - 84.
- Sampson H.A. (1996) Managing peanut allergy in: British medical journal, Apr 27, Vol 3 (12), pg. 1050-1051
- Science Daily (2007) Food Scientist Develops For Allergen-Free Peanuts, According to Lab, Retrieved on 20th November 2009 from the World Wide Web: http://www.sciencedaily.com/releases/2007/07/070723165825.htm
- Trickett, J. (2001) The Prevention of Food Poisoning, 4th edn, Cheltenham: Nelson Thornes Ltd.
- University Hospital South Manchester (no date) Peanut and Tree Nut Allergy, Retrieved on 12th November from the World Wide Web: http://www.uhsm.nhs.uk/patients/Paediatrics%20Documents/Peanut%20and%20Tree%20Nut%20Allergy%20Information%20for%20Parents.pdf.
- Worsfold, D. (2008) Raising food allergy awareness of caterers in Wales, in: Nutrition and Food Science, Vol 38 (5), Emerald Group Publishing Limited, pg. 417 - 421.