Plenty of people suffer from at least one irksome dietary dilemma—and I’m one of them. A few bites of cantaloupe will set my mouth and throat afire with an itchy, prickling sensation. Eating too much gluten gives me splitting migraines. And one gulp of milk is all it takes to guarantee me the kind of gastrointestinal distress that can clear out an entire auditorium.
It might come as a surprise that I’m not allergic to any of these foods.
An undoubtedly complex lingo surrounds food allergies and intolerances, and many people incorrectly self-diagnose without input from a medical professional. But the confusion can have far worse consequences than a misuse of terminology: For food service staff, misconceptions about dietary restrictions can lead to real-world mix-ups—a serious risk in a country where an allergic reaction to food sends someone to the emergency room every three minutes.
In the past decade, studies from around the globe have revealed consistent gaps in knowledge in the food service industry. Around a quarter of food establishment personnel are under the false impression that customers can safely consume a small amount of the foods they’re allergic to. And about a third think drinking water can dampen the severity of an ongoing reaction.
Given the increasing prevalence of food allergies, these findings are “very concerning,” says Ruchi Gupta, an allergist and pediatrician at Lurie Children's Hospital Chicago. But there’s little point in assigning blame to one party or another. “Food allergies are complex, and the symptoms can affect almost any organ system in the body,” she says. “It’s hard for the general public to know what they have [when] there are so many food-related conditions.”
Nothing to sneeze at
When it comes to food, the terms “allergy,” “intolerance,” and “sensitivity” are often used interchangeably, but they each mean different things. Most critical are food allergies, which involve an inappropriate immune system response to a specific food. A person with a severe nut allergy, for instance, may manufacture molecules called IgE antibodies that incorrectly identify proteins present in almonds as dangerous and rouse immune cells into action. This can trigger a cascade of symptoms, sometimes culminating in life-threatening anaphylaxis.
But the symptoms of such “classic” food allergies aren’t always clear cut, Gupta says. Because the immune system is linked up to so many other parts of the body, allergies can manifest differently from person to person.
Currently, there are no cures for food allergies, and they can develop (or even resolve) at almost any age. Definitive diagnoses can only be made by allergists, who will look for a reaction after injecting a tiny dose of the allergen under the skin. But these tests also sometimes misidentify patients as allergic who actually aren’t, says Jennifer Kim, an allergist at NorthShore Medical Group in Illinois.
Complicating matters are related, but separate, conditions like oral allergy syndrome. People who suffer from pollen allergies have mild reactions to certain fruits or vegetables that make proteins resembling pollen. This immunological imposter act happens with ragweed and cantaloupe—that’s why my mouth tingles when I eat fruit salad, even though I’m not technically allergic to its ingredients.
Another common mix-up happens with celiac disease, an autoimmune condition that involves gluten (a protein found in wheat, barley, and rye), but has some clear-cut distinctions compared to, say, an actual wheat allergy. In people who have celiac, the presence of gluten in the digestive tract prompts the production of IgA antibodies, which are distinct from the IgE antibodies active in classic food allergies. Problems arise when IgA antibodies target not gluten, but the lining of the small intestine. With continued exposure to gluten, this can lead to a chronic condition in which the body has trouble absorbing nutrients—but a single encounter with gluten won’t spark an immediate allergic response.
Food intolerances are more of a gray area. These refer to a negative reaction to a food, like bloating, nausea, or headaches, that doesn’t involve the immune system. My gluten and lactose intolerances, for instance, don’t make me allergic to either of these foods—but they do cause me quite a bit of discomfort. Unlike the case with allergies, trace amounts of these foods don’t carry the risk of an immediate, life-threatening reaction. And, barring a false positive, intolerances won’t flare up after an allergy skin test.
In other words, intolerances are defined by what they aren’t, rather than what they are, making them a challenge to diagnose and explain. Part of the reason is that there’s no clear-cut constellation of symptoms or rapid fire test that can distinguish an intolerance from an allergy, causing many to conflate the two, says Onyinye Iweala, an allergist at the Division of Rheumatology, Allergy, and Immunology of the University of North Carolina’s School of Medicine.
Last and definitely least, food sensitivity is “kind of a blanket term that doesn’t really mean anything specific,” Gupta says. In most cases, this phrasing is too vague to be helpful.
Lost in translation
Unfortunately, “food allergy” has become a catchall phrase. Gupta’s own research found that, in a survey of 40,000 United States adults, 19 percent of participants claimed to suffer from a food allergy—but only about half of these people actually reported allergic symptoms.
While these statistics may seem to cast an unflattering light on some Americans, the more important takeaway is that up to a fifth of people could have some condition—perhaps an intolerance—that’s probably causing them to avoid certain foods, Gupta says.
As these terms are bandied about, they can create a frustrating dialogue between those trying to eat out and the employees trying to serve them. In a study published today in the journal PLOS ONE, almost a fifth of restaurant staff surveyed in Germany indicated they would prefer not to serve patrons with food allergies.
The new study, like many before it, also underscored a persistent lack of knowledge in the restaurant industry—with potentially dire repercussions, says Adrian Loerbroks, a social epidemiologist at the University of Düsseldorf in Germany who led the research. Of nearly 300 personnel surveyed, only 30 percent could name three food allergens, and almost 10 percent were unaware food allergies could be fatal. Almost 20 percent of participants thought removing an allergen from a finished dish (like picking the nuts off a salad) would render a meal safe for an allergic customer. And more than 40 percent believed some of the food allergies brought up by their patrons weren’t real.
Other incorrect beliefs have been highlighted by past research, such as the idea that cooking food can prevent an allergic reaction. Despite these patterns, the new study is among several that show a large majority of restaurant staff feel confident in their ability to provide their customers an allergy-safe meal. Although managers tend to be better informed than wait staff, it’s the latter who are “on the frontlines of interacting with customers,” Iweala points out.
We reap what we sow (and sometimes, it gives us indigestion)
Scott Sicherer, an allergist at Mount Sinai’s Icahn School of Medicine, cautions that none of this research should be used to demonize restaurants or their staff. “People in a restaurant don’t want you to get sick,” he says. “But they may not know everything they need to know to make sure you don’t get sick.”
After all, the logistics of juggling food allergies and intolerances aren’t trivial. In a typical food establishment, an order can pass through multiple servers before it reaches a team of chefs in a chaotic kitchen. If just one person in this complex chain misses the message, or underestimates the danger of the situation, the system can quickly break down.
“It’s frustrating for these people,” Kim says. “They’re not doctors, and even doctors can’t tell from a short, verbal interaction if [a customer] has an allergy or intolerance...it’s a challenge to make sure that every meal is safe.”
Part of the problem is that there isn’t a universal mandate for handling food allergies in dining establishments. While the United States Food and Drug Administration’s Food Code includes information on allergies to guide members of the food service industry, it’s up to individual states to adopt the Code, and participation varies across the country.
Smaller scale hurdles exist as well. For one, with the sheer diversity of food establishments that exist in the United States, from pop-up food carts to Michelin-starred restaurants, it wouldn’t be practical to implement a one-size-fits-all strategy. And since the food industry has a very high turnover rate and many young employees, it’s difficult for eateries to keep their staff up-to-date, says Abhinand Thaivalappil, a public health researcher and food safety expert at the University of Guelph in Canada.
That being said, things have vastly improved over the past 15 years, Gupta says. Many menus now list common allergens, or prompt patrons to inform their servers of any allergies. (On the flip side, some restaurants explicitly state that they can’t accommodate patrons with serious food allergies.) In many restaurants, wait staff will even explicitly ask about dietary restrictions before taking an order.
However, Gupta, Kim, and Sicherer agree that better training in eating establishments will be key to keeping people safe. Restaurant staff members who have undertaken formal education on food allergies remain in the minority, and several studies have hinted that existing programs haven’t done much to improve knowledge.
At a minimum, members of an establishment should have two basic sets of knowledge, Thaivalappil says. First, staff should feel comfortable asking about and handling common food allergies (the eight most common are milk, eggs, tree nuts, peanuts, shellfish, wheat, soy, and fish). Second, if exposure occurs, restaurant personnel should be able to pinpoint the typical symptoms of a reaction and take action by calling 911 or ensuring the patron uses their EpiPen.
Having these measures in place would probably alleviate a lot of concerns on both ends, Gupta says. “People [with allergies] definitely avoid eating out, or have just a few safe places where they’ll go,” she says. “So restaurants do have something to gain from being food-allergy-friendly.”
At the same time, the burden shouldn’t fall entirely on the shoulders of restaurant staff, Thaivalappil says.
“If you’re the customer, don’t be afraid to ask questions,” he says. “Both parties need to do their best to minimize the risk of reaction. It’s your health on the line, and you’re just as responsible.”