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Sponsor Disclosure: Support for this presentation was provided by the Foodservice Express division of Med-Diet, Inc. The material herein is for educational purposes only. Reproduction or distribution of these materials is prohibited except as expressly provided by Med-Diet, Inc. or the presenter.

Copyright 2013 Med-Diet, Inc. All rights reserved.

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Serving Up Allergy FreeA Focus On Food Allergies and Intolerances

Program Objectives

• Review major food allergies and intolerances and their respective dietary implications

• Discuss navigating food labeling and identifying hidden allergenic ingredients

• Provide ideas for an allergy-friendly food prep & service

Did you know?

• Any food can cause an allergic reaction.• Corn, gelatin, grapes, onion, tomato, banana, apple

• Stone fruits: plum, peach, nectarine, cherries

• Meats: beef, chicken, mutton, pork,

• Seeds: sesame, sunflower, poppy

• Spices: caraway, coriander, garlic, mustard

• Different countries have different “top” allergens

• People can have many different types of allergies besides foods. • Sometimes leading to cross-reactions

Prevalence

•Clinically diagnosed Food Allergy•5% of children•4% of adults

•Food Intolerance / Sensitivity•Not quantifiable•1:3 people claim issues

Definition - Allergy

• Abnormal response to a ‘normal’ food

• Triggered by immune system• Body produces antibody IgE

• Reaction may be immediate to hours after exposure

• Response ranges from mild to severe

• Risk is tied to genetics

• Proteins in the offending food have survived usual breakdown from cooking, stomach acids and/or digestive enzymes

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Allergic Response

• Response & timing unique to individual

• Protein fragments are introduced and allergic reactions follow• Itching in mouth as food is eaten

• Abdominal discomfort with digestion• Vomiting, diarrhea, GI pain

• Allergens in bloodstream• Drop in blood pressure

• Upon reaching the skin → hives, eczema

• Reaching the lungs → wheezing

Oral Allergy syndrome

•Allergy to pollen creates an issue with raw fruits/vegetables•Localized to mouth /oral cavity / throat•Cooked item is tolerated

Definition - Intolerance

• Intolerance / Hypersensitivity - Not a true allergy• Non-IgE mediated

• Abnormal physiological response to food or food compound

• Not tied to genetics

• Varied mechanisms of action:• Metabolic: absence of chemicals/enzymes to digest a food

• Lactose, fructose intolerance

• GI: Inability to absorb nutrients• Fructose malabsorption

• Pharmacologic: natural/artificial food chemical sensitivity• Salicylate, sulphites, nitrate

Intolerance/Sensitivity Response

•Chronic vs. acute, less obvious

•Dose / exposure dependent

•Symptoms vary greatly•Skin: rash, hives, dermatitis, eczema•Respiratory: nasal congestion, sinusitis, throat

irritation, asthma, cough•GI: mouth ulcers, cramping, nausea, gas, diarrhea,

IBS•Anaphylaxis

Top 8 Food Allergies

Milk

Eggs

Wheat

Soybeans

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Peanuts

Tree Nuts

Shellfish

Fish

Egg Allergy

• 6 billion eggs produced/distributed monthly

• Affects 0.2% (600,000) Americans• 70% outgrow allergy by age 16

• Most common reaction is skin related • Often as eczema in infants / younger children

• Food sources: egg, egg dishes, baked goods

• Hidden sources: canned soups, salad dressings, ice cream, mixed meal dishes (meatloaf)

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Egg Allergy

• White or Yolk?• Allergy may be to either but neither should be eaten

• Eggs in mixed foods (baked goods)• Reaction not predictable

• Baking substitution:• 1 Egg = 1 ½ Tbsp water + 1 ½ Tbsp oil + 1 tsp baking

powder

OR

• 1 Egg = 1 tsp yeast dissolved in ¼ cup warm water

• Maximum recipe replacement is for 1-3 eggs

Fish Allergy

• 20,000+ species of fish • Avoid them all (unless allergist advises otherwise)

• Affects 0.4% of population• More women than men

• Often develops in adulthood• Children not excluded

• Reactions range BUT anaphylaxis is common

• Food sources: fish and fish dishes

• Hidden sources: Worcestershire sauce, Caesar salad, surimi (imitation crab), fish stock, Asian cuisine

Fish Allergy

•Fish vs. Shellfish•Usually not connected•May be advised to avoid both

•Challenge•Cross contamination•Mislabeling

Milk Allergy

• Common allergy in children• IgE mediated

• Non IgE mediated

• Affects 300,000 children under 3 yrs• 80% outgrow allergy by16 yrs

• Common reactions • Blood in stool, vomiting, hives

• Food sources: milk and milk products

• Hidden sources: casein, whey

Milk Allergy

• ~75% of those with allergy can tolerate some milk containing foods

• Milk has been extensively heated (e.g. baked goods)

Milk allergy versus lactose intolerance

• Not related• Allergic reaction is to the protein and will be more

severe

• Intolerance is not tied to milk protein but the sugar lactose• Lack enzyme lactase to digest the milk sugar

• People with intolerance • Small dose of milk products okay

• Especially in context of mixed meal

Peanut Allergy

• Not a nut!

• Affects 400,000 children• Incidence has tripled from 1997-2008

• ~20% outgrow allergy

• Associated with severe reactions• Unpredictable

• Epi pen usually needed

• Sources: baked goods, ice cream toppings, cuisines (Asian, Mexican), candies

• Hidden sources: cross contamination

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Peanut allergy

• How close is too close?• Cases have been reported resulting from nearness and smell

BUT

• Blind, placebo controlled trial of children showed no systemic reaction

• Peanut protein could become airborne (via grinding)• Response usually not anaphylactic

• Smell triggers something physiologic• Rash, BP

• Most can consume peanut oil

Shellfish allergy

• One of top food allergens for adults• Not usually out grown

• Affects ~2.7 million people (2.3% of population)

• Includes crustacean group:• Shrimp, lobster, crabs

• Mollusks potentially tolerated – scallops, oysters, clams, mussels

• Food sources: fish stock, flavorings, sushi, surimi

• Hidden sources: cross contamination

Soybean Allergy

• A legume

• Affects 0.4% of children (~300,000) under 18 yrs• About 70% outgrow allergy

• Reactions are typically mild• Anaphylaxis is rare

• Food sources: soy milk, tofu, infant formulas, soy nuts, Asian cuisine

• Hidden sources: processed meats and foods, canned soups, low fat and alternative peanut butters, vodka

Soybean Allergy

• Soybean oil?

• Soy lecithin?

• Soy Allergy = Peanut Allergy?• No, not related.

Tree Nut allergy

• Affects ~1 million people• Lifelong allergy; <10% out grow it

• Serious and often linked to anaphylaxis

• Although NOT linked about 28-50% of people with peanut allergy will be allergic to at least 1 tree nut

• May be able to tolerate nuts other than the one(s) allergic to

• Sources: walnut, pecan, almond, pistachio, lichee nut,

• Hidden sources: baked goods, candy, garnishes, sauces, stuffed toys

What is not a Tree Nut?

•The NOT nuts•Coconut (fruit)

• Although FDA classifies coconut with tree nuts

• Reports of allergic reactions

•Nutmeg (spice derived from seeds)

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Wheat Allergy

• ~75% of all grain products in the US contain wheat flour

• Affects 0.4% of children and 0.5% of adults• ~65% of children typically outgrow

• Reactions span mild to severe

• Food sources: breads, pastas, processed foods

• Hidden sources: processed foods, cosmetics, bath products, play dough

Wheat Allergy

• Generally tolerated grains:• Aramanth

• Barley

• Buckwheat

• Corn

• Oats

• Millet

• Rice

• Rye

• Sorghum

• Quinoa

• Gluten Free is good for Wheat Free BUT Wheat Free is not always for Gluten Free

Gluten Intolerance

• Symptom of Celiac disease• An example of a cell-mediated allergy

• Both an intolerance (hypersensitivity) and an autoimmune disorder

• Affects ~1% of population or 1:133 people• Hereditary

• Lifelong disorder

What is Celiac Disease?

•Triggered by gluten in wheat, rye, and barley in the diet

• Inflammation of the small intestine mucosa

•Causes malabsorption of nutrients• Sets off intestinal symptoms &/or extra-intestinal

symptoms

Clinical Presentation

• Abdominal pain, gas &

distention

• Chronic diarrhea

• Vomiting

• Constipation

• Pale, foul-smelling or fatty stool

• Weight loss

• Failure to thrive/short stature

• Unexplained iron -deficiency anemia

• Bone / joint pain

• Arthritis

• Bone loss or osteoporosis

• Depression or anxiety

• Tingling numbness

• Infertility and recurrent miscarriages

• Dermatitis Herpetiformis

Younger Age Onset Adult Onset

Common Sources of Gluten

BulgurCouscousDurum EinkornEmmerFarinaTriticaleKamut

Graham flourMatzo flour & mealSpelt/speltaWheat germWheat starchBarley malt & extractSemolinaHydrolyzed Vegetable Protein (HVP)

BranOrzoPankoSeitanUdonFaro

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Hidden Sources of Gluten

• Processed dairy products

• Processed fruits and vegetables

• Processed meats, fish, poultry

• Soups and bouillon

• Matzo and communion wafers

• Lipstick, toothpaste, chewing gum, mints

• Licorice and some candies

• Breading, coating mixes, croutons, stuffing/dressing mixes

• Roux, thickeners

• Soy sauce, marinades

• Modified food starch, malt and malt flavoring

• Supplements

• Medications

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Fructose Intolerance

• Hereditary disorder• Both parents carrying gene → 25% chance child has

• Body missing enzyme aldolase B • Body’s glycogen cannot be changed into glucose• Blood glucose drops• Dangerous substances build up in liver

• Both fructose AND sucrose are problems• And sorbitol

• Onset in infancy• Irritability, jaundice, vomiting, convulsions

• Treatment is to remove the offending sugars from the diet and take Rx to lower uric acid & risk for gout

• Mild or severe• Can lead to liver disease despite treatment

Allergy Prevention - POINT

• Evidence for prevention = weak

• Strategies to possibly reduce risk:• Exclusive breastfeeding first 6 months OR use

of hypoallergenic formula

• Delay introducing:• solids until 6 mo.

• cow’s milk until 1 yr.

• Eggs until 2 yrs.

• Peanuts, tree nuts, and fish until 3 yrs.

Allergy Prevention-Counter POINT

• Full circle• Introduce allergens earlier

• Exposure may be better than avoidance

• Controversial • How to assess an

“uncommunicative” infant

• Extenuating information• Classic symptoms show (eczema)

• Siblings with allergies

Food Allergen Labeling

Consumer Protection Act

(FALCPA) of 2004

Thou Shalt Not Hide the top 8

• http://www.fda.gov/Food/LabelingNutrition/FoodAllergensLabeling/GuidanceComplianceRegulatoryInformation/ucm106187.htm

• Labels must list ingredients using common names• Sodium caseinate (milk)

• Every ingredient source from the top 8 allergens must be disclosed

• Species must be declared for nuts, fish & shellfish

• Gluten Free rule – just came into law in 2013

• NOT covered under this law • Meat, poultry & eggs fall under USDA

• Alcohol falls under ATTB

• Drugs (Rx & OTC), Cosmetics, Health & Beauty items

• Kosher Labeling

• Restaurant foods

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Gluten-Free Labeling

•Published Sept. 2013 Enforced August 5th 2014

• “Gluten-free”; “No Gluten”; “Free of Gluten”; Without Gluten

•Means the food does NOT contain:• An ingredient that is a gluten-containing grain

• An ingredient derived from a gluten-containing grain

• Unless it has bee processed to remove the gluten

• <20 ppm of gluten is threshold

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Foods Not Subject to FALCPA

• Raw foods• Whole fruits, vegetables

• Foods approved as exempt

• Molluscan shellfish• Oysters, clams, mussels, scallops

One more Caveat

• Any law is only as good as the ability to enforce it.

• Label omission vs. commission

• Imported goods – should follow rules of destination country

Ingredient U.S. Canada

1 Tree nuts almonds, beech nuts, Brazil nuts,

butternuts, cashews, chestnuts,

chinquapins, coconut,

filberts/hazelnuts, ginko nuts,

hickory nuts, lichee nuts,

macadamia/bush nuts, pecans, pili

nuts, pine/pinon nuts, pistachios,

sheanuts, walnuts

almonds, Brazil nuts,

cashews, hazelnuts,

macadamia nuts, pecans,

pine nuts, pistachios or

walnuts

2 Peanuts

3 Soybeans

4 Wheat any species in the genus

Triticum , including common,

durum, einkorn, emmer and club

wheat, as well as spelt, semolina,

kamut and triticale

any species in the genus

Triticum including wheat,

triticale and all related

hybrid varieties (e.g. kamut,

spelt)

5 Eggs

6 Milk

7 Fish common name of fish common name of fish

8 Crustacean

shellfish

common name of crustacean

(e.g. crab, lobster, shrimp)

common name of

crustacean (e.g. crab,

lobster, shrimp)

9 Mollusk

shellfish

no requirement for allergen labeling common name of mollusk

(e.g. clams, mussels,

oysters, squid)

10 Sesame seeds no requirement for allergen labeling

11 Mustard seed no requirement for allergen labeling

12 Gluten sources

other than

wheat

no requirement for allergen labeling barley, oats and rye, and

related derivatives

Voluntary Labeling

• How many ways can we say “maybe”?• May Contain: Peanuts

• Produced on equipment that also makes product containing peanuts.

• Processed in a manufacturing plant that also processes peanuts.

• Produced in a facility that also handles peanuts.

• This product is manufactured on equipment that also processes peanut containing products.

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Label Sleuthing

• Know the source• USA major manufacturer vs. Mom/Pop shop

• Imported vs. US based

• If in doubt• Call the manufacturer and ask

• Don’t serve the item

Taking it into the kitchenAllergies, Intolerances and Foodservice

The allergy friendly kitchen

Obligation does not end with buying the right food(s)

• After the menu, recipe and label sleuthing….

• Reduce Cross-Contamination:• Storage

• Prep

• Serving

Train Staff

Train Staff

• Vulnerable populations• Don’t let people with allergies trade foods

• Day care settings

• School cafeteria

• LTC – dementia and Alzheimer residents

Risk Management

• Know ingredients in menu items• Ingredients change

• Have a foodservice “lead” (all shifts) assigned to respond to questions, special requests

• Identification of a food allergy should ignite a process

• Train staff to know what in the event of an allergic reaction

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Remember

• It's not (necessarily) a foodservice task to distinguish between allergies, intolerances and aversions.

• If clients don't want a particular food item, it is the job of food service to avoid serving it.

Reference & Resource

• American Academy of Pediatrics

• American College of Allergy, Asthma, & Immunology

• Fleischer DM et al., J Allergy Clin Immunol: In Practice. 2013;1:29-36.

• International Network for Diet and Nutrition in Allergy

• Kids with Food Allergies

• The Food Allergy & Anaphylaxis Network

• US Food and Drug Administration

Thank you for participating in today’s session!

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This presentation is intended to provide general information about managing food allergies and

intolerances but is not intended to provide medical advice.

Presentation Author: Debra Zwiefelhofer, RD, LD

Your Special Diet Partner

Post Test

1. Name the top 8 allergens that result in 90% of food allergies in the US.

2. List at least 3 things that need to be done in the kitchen to reduce risk of cross-contamination.