As many start the new year with resolutions to consume a more plant-based diet, we should spare a thought for the food allergic patient negotiating an increasing array of food hazards. As a Consultant Allergist, I frequently hear patients discuss their experiences of eating out. A common theme has emerged recently regarding reactions to vegan food.
Persistent anaphylactic milk and egg allergy is an increasing phenomenon in the context of our allergy epidemic. Patients with milk and egg allergy are at high risk of reactions to these common ubiquitous foods. It might seem an attractive prospect to eat vegan food if suffering from this dual blight on dietary choice. However, choosing vegan does not guarantee that the product is free of cross-contamination with food allergens and this is likely to be more of a problem in restaurants serving vegan options alongside dairy and egg-containing foods. Additionally those with co-existing nut allergy may be at risk of nut cross-contamination or substitution of a nut-based product such as cashew nut butter or cheese.
Caterers are required by law to provide safe food—clearly it must not contain pathogens or toxins. Equally, if the customer has stated they are allergic to specific foods, there is an obligation to provide safe food free of these food allergens. Food businesses are obliged to comply with the general hygiene requirements in Annex II of the food hygiene regulation and this includes provision regarding allergens. I have heard from patients who have decades of experience living with food allergy that reactions have occurred to vegan foods despite their request for milk and egg allergen free or nut free food. This is disrespectful and dishonest to those making an ethical choice to eat vegan food, but could be fatal to the food allergic diner. Caterers must by now be aware that a jail sentence for gross negligence manslaughter can follow when a reaction to an unexpected food allergen proves fatal.
Many people with food allergies feel so unwelcome or unsafe in restaurants that they rarely eat out. This contributes to a significant impact on quality of life. Why should food allergic customers not be able to enjoy eating out without fear of a reaction?
It is necessary for people with food allergies to be equipped with clear advice on how to avoid foods they are allergic to. They need an understanding of the many ways in which hidden allergens can present in processed food, and advice on how to approach eating out safely. This includes a consideration of cross-contamination in restaurants and availability of written information on food allergens.
Referral to an allergy clinic ensures that patients have a full risk assessment, including avoidance advice, training in the use of emergency medicines and emphasis on good asthma control. For their part, the food industry needs to step up to provide safe food to all. This requires that staff training is effective and communication of a diner’s dietary requirements is 100% reliable. All catering staff must be well informed about the importance of allergen avoidance and the risks of cross-contamination. This cannot be assumed to be general knowledge. Staff training must highlight that vegan foods are not the same as “free from” products unless clearly indicated as such. It would help if food allergic customers were also considered in the development of vegan foods the so that precautionary labelling for milk and egg is not still a problem with these products. After all, it seems likely that vegans would also prefer this.
Once a patient arrives at the emergency department with food anaphylaxis the priority is to treat the presenting symptoms effectively. It is also very important to document as much information as possible about the food eaten preceding the reaction. The patient must be advised to obtain details of the ingredients so that any hidden allergens are identified. With long waits for allergy clinic appointments, this information may have been forgotten or be unavailable by the time they are investigated. The diagnostic value of tests is diminished when the suspected trigger to the reaction is unknown—skin testing and IgE testing is subject to false positivity and false negativity. My experience is that precise information is rarely recorded at the time of the reaction and this also needs to change.
There has been an huge increase in the offer of vegan food to satisfy a growing market—yet those with food allergies remain under-represented. Their requests for safe food are often not respected and in many restaurants they cannot be guaranteed a safe meal. Caterers need to grasp this simple truth—they must provide all their customers with safe food now, before another tragedy occurs.
Cecilia Trigg is a consultant allergist at St Mary’s Paddington. She has a special interest in food allergy and transition of young people with multiple and severe allergy from paediatric care.
Competing interests: None declared.