Eating out is meant to be an enjoyable experience, one in which concerns about safety should not feature. But, unfortunately, not all food that is served up in restaurants is safe. Apart from the well-known risks of food poisoning and of food intolerance, such as from gluten sensitivity, there is the important and yet unresolved matter of food allergy. This is particularly important, as severe food allergies can be life threatening and continue to be responsible for tragic losses of life.
Owen Carey died after eating half of a grilled chicken burger on his eighteenth birthday, on April 22 2017, at a Byron restaurant in the O2 Arena in North Greenwich. He was known to be allergic to dairy products, and had even been prescribed an EpiPen for this reason. The chicken had been marinated in buttermilk. This fact was not made known to Owen, who had an anaphylactic reaction and died soon thereafter.
So, how common is the problem? According to the Food Standards Agency, an estimated two million people in the UK have a food allergy. Food allergy is responsible for around 4,500 admissions to hospital and an average of ten deaths a year. All such deaths are potentially preventable and are particularly tragic given the circumstances in which they take place.
Any foreign protein can cause an allergic reaction. The term anaphylaxis was first used by Charles Richet, a French physiologist, in 1902 to describe an exaggerated response to foreign proteins in response to repeated exposure. Most allergic reactions to food are, however, less severe. These reactions include the oral allergy syndrome of itchiness inside the mouth and throat, the itchy and blotchy skin rash known as urticaria, and the swelling of the face, particularly involving the lips, tongue and roof of the mouth, that is known as angioedema.
A variety of foods or food ingredients can trigger allergic reactions. These substances include peanuts, tree nuts, and seafood (fin fish and shellfish) in adults, and peanuts, tree nuts, cow’s milk, hen’s eggs, soy and wheat in children. Less commonly, fruits, gelatin, chocolate, meats, seeds, and spices may cause allergic reactions. Some allergens are cross-reactive, and allergy to one substance can predict allergy to other similar substances. Food reactions that are mediated by antibodies known as immunoglobulin E develop immediately and progress rapidly after exposure to the responsible allergen. Anaphylaxis falls into this category.
Anaphylaxis is a life-threatening allergic reaction characterised by widespread dilatation, or abnormal widening, and an increase in the permeability, or leakiness, of blood vessels, and an intense contraction or spasm of smooth muscles, such as those in the bronchial tubes of the lungs (bronchospasm). Leakage of fluids through the capillary blood vessels reduces the effective circulating blood volume and leads to a catastrophic drop in blood pressure. Swelling of the airway passages and bronchospasm cause a difficulty with adequate oxygenation of the blood. An intramuscular injection of adrenaline or epinephrine is the single most important initial treatment, followed by fluid replacement and other supportive measures.
Practices are changing in the restaurant business as awareness and knowledge of food allergy continue to improve. Servers are being trained to ask clients about any food allergies before accepting their orders. Menu cards provide reminders to customers to inform restaurant staff about any known allergies. However, when a restaurant is busy and servers are rushed, good practices may be overlooked, and more so when there is a lack of training. Furthermore, the actual listing of ingredients in individual dishes, where available, may be incomplete as well as inaccurate. In addition, unintended cross-contamination with other undocumented allergens may result from deficient kitchen practices, such as using the same cooking oil for different dishes.
Convenience of use has increased the popularity of pre-packed foods. Natasha Ednan-Laperouse, 15, died on a British Airways flight on July 15 2016, after eating an artichoke, olive and tapenade baguette that had been purchased from a Pret a Manger outlet at the airport. The baguette contained sesame seeds, to which she was severely allergic, and Natasha was unaware of this. Her parents have subsequently been involved with several initiatives related to food allergy. Natasha’s Law, which is to be implemented by the UK government from the summer of 2021 onwards, will require a full list of ingredients, with emphasis on allergenic substances, to be provided with all pre-packed food.
Practice in restaurants remains less stringent and is highly variable. The Food Standards Agency recommends that fourteen main types of allergens have to be specifically listed by restaurants. But this listing does not have to appear on the menu card itself, but can also be provided in written form elsewhere within the restaurant, as for example on chalkboards. There is a way to go yet before standards are set and uniformly maintained to a high standard.
Some anaphylactic reactions may happen unexpectedly. In such situations, after treatment, the victim should ideally be seen by an allergy specialist. Unfortunately, there is a shortage of such specialists in the NHS, which means that food allergies can be misdiagnosed and may not be treated according to best practices. In situations where repeated exposure to the identified allergen is likely, the affected person should be provided with and trained to use an EpiPen, an adrenaline auto-injector pen device, which allows self-administration of adrenaline as soon as there is any warning of possible anaphylaxis. Ideally, a medical alert bracelet or necklace should also be worn by the person, to alert anyone who has to help them in case of an emergency.
New treatments are being developed to reduce the frequency and impact of severe allergic reactions. Oral immunotherapy involves gradual desensitisation to foreign proteins through repeated exposure at small doses. Thus, a new drug for peanut allergy, Palforzia, has been recommended in the US by the FDA’s Allergenic Products Advisory Committee in September 2019. Palforzia contains peanut protein and can be administered once a day, mixed with certain foods, to allow desensitisation to peanut exposure.
Irrespective of such developments, the onus is on food manufacturers and servers to clearly label or otherwise identify all ingredients that have been used in the preparation of food. This will ensure that people with known severe allergies to certain ingredients can avoid inadvertent and unintentional exposure to the same. Much needs to be done across the restaurant trade in particular, given the wide range of establishments available, before safety can be guaranteed while eating out.
Ashis Banerjee (have treated many people with anaphylaxis)