By P.K. Daniel

Stephanie Leonard, MD, is a food allergy specialist at Rady Children’s Hospital-San Diego – and she also happens to have a life-threatening allergy to peanuts. “Every time I put food in my mouth, I’m reminded of my food allergy,” she says.

Recently, Dr. Leonard ordered a pesto dish at a local restaurant; the server assured her it did not contain peanuts. A half-hour after eating her meal, she started to feel an allergic reaction. As symptoms worsened, Dr. Leonard quickly pulled out her epinephrine auto-injector and administered the medication.

Turns out that while the pesto dish did not contain peanuts, the pine nuts in the pesto had been were put in the same grinder used for peanuts. Even though it was a tiny amount of peanut, cross-contact – in which a food allergen is transferred to a food that does not contain the allergen, usually during the cooking process – had occurred, putting her at risk for anaphylaxis, a life-threatening allergic reaction.

Dr. Leonard, 38, is a self-described “foodie” and she is determined to keep dining out, whether it’s for a  festive occasion, or simply when the mood strikes her. She checks menus online, communicates with restaurant staffs and avoids cuisines likely to cause an allergic reaction. And she always carries two epinephrine auto-injectors, the first line of treatment for anaphylaxis.

“Most restaurants have good intentions, but there’s always the possibility of a misunderstanding or cross-contact with a food allergen, so you need to be prepared,” she says. “Both the customer and the restaurant staff have to communicate clearly and be prepared.”

“If you have a food allergy, any time you go out to eat, you have to be prepared in case you have an allergic reaction – so having an epinephrine auto-injector is the most important thing,” says Andrew White, MD, an allergist and immunologist with Scripps Health in San Diego. “Ultimately, no matter how much you trust the restaurant or the chef, you’re never going to know for sure what’s going on in the kitchen. So be prepared and protect yourself.”

Putting Safety First

Eating out is an American pastime – even for the approximately 15 million who have food allergies. With almost half of all meals purchased away from home, it can be difficult for food-allergic patrons and people with dietary restrictions to go to restaurants and enjoy a meal without avoiding a severe allergic reaction.

As food allergy prevalence has increase – by 50 percent among children between 1997 and 2011 – many restaurants have responded positively. Some popular chains, including McDonald’s, Rubio’s and Panera Bread, list allergens in their online menus. Disneyland and Disney World have long had accommodations in place for consumers with special dietary needs.

Some restaurants go beyond the norm.

Since 2007, chef Keith Norman has directed a food allergy training program at South Point Hotel, Casino and Spa restaurants in Las Vegas. Norman has friends and family with life-threatening food allergies, so he is passionate about safety.

“I’ve tried to put systems into place where we can safely serve the food-allergic patron, and when we can’t we’re going to say we can’t,” he says.

When a food-allergic customer’s order is entered into the computer at South Point, the server selects an allergen-alert button and it’s printed on the order in red letters to alert the chef. When the order is delivered to the kitchen, the chef assigns it to one cook, who is the only one who will touch that dish.

Susana Cabrera has been a food server at Baja Miguel’s restaurant at South Point for six years. Every year, she gets retrained in safe food-handling practices centered around food allergies.

“As a server we always have to be very aware of food allergies,” said Cabrera, who notes she serves a food-allergic customer almost daily. “It’s very important to make sure we communicate with the customer and our chef exactly what the allergy is and what was ordered to make sure the food comes to the table safely.”

Allergy-safe kitchen safeguards include a special area to prepare meals, with clean pots, pans and cooking utensils at the ready; changing gloves to make allergen-free foods; and using special color-coded cutting boards to prepare allergy-safe meals. These strategies take guesswork out of what foods have and have not been cross-contacted with an allergen.

South Point servers also make a point to serve food-allergic customers first so their food does not come into contact with any other food being served.

Norman’s approach to food allergies has resulted in repeat customers. “They feel safe here,” Cabrera says.

Menu Minders

Allergens can hide in unexpected places, such as a sauce, gravy or dressing. Peanut butter, for example, can be used as a thickener in spaghetti sauce, chili or mole. And milk can be one of the most difficult allergens for restaurants to deal with because it’s in so many dishes as butter, cream, cheese or an egg-wash breading.

It’s one of many reasons why food allergy awareness by restaurant staff is essential.

In recent years, states and cities across the country have made it a priority to require food allergy education and training at restaurants. Illinois, Massachusetts, Michigan and Rhode Island require restaurants have at least one manager who is certified or trained in food allergy awareness and safety.

Maryland, Massachusetts and Rhode Island, as well as New York City and St. Paul, Minnesota, require restaurants to place food allergy awareness posters in the staff area. The posters typically identify the eight foods – peanuts, tree nuts, milk, egg, shellfish, fish, soy and wheat – accounting for 90 percent of food allergies in the United States, and provide information on how to accommodate food-allergic diners.

Cindy Walter, who has multiple food allergies, co-owns Passionfish in Pacific Grove, Califorinia, with her chef husband, Ted Walter. Together they always keep food-allergic diners in mind.

The Walters designed a menu that lists the potential allergens in each dish, displayed in an easy-to-read, color-coded format.

“We have a sea scallop appetizer with a caper raisin walnut relish and artichoke risotto cake, so on the menu, all the different possible allergens in the dish are listed in different colors,” Cindy explains. “The sea scallop appetizer contains dairy, shellfish and nuts. It also contains gluten, and we mention that as well.

“The color-coded menu has worked remarkably well. It makes it easier for the guest and the server. It’s something any restaurant could do.”

Inside the kitchen

Allergists recommend that restaurants have a separate area to prepare food, including clean pots, pans and utensils at the ready to make the meal for the food-allergic patron.

In addition, patrons can take precautions by avoiding certain cuisines. For example, people allergic to peanut, tree nuts or sesame may want to avoid Asian, while people with dairy allergies may want to avoid Italian.

“It’s not that you can never dine out,” says Faith Huang, MD, an allergist and immunologist at Allergy and Asthma Associates of Southern California. “But when you do, you need to be cognizant of what is in the food. You need to talk to the person who’s actually preparing the food.

“It’s okay to tell the chef about your allergy, and that the pans and all of the utensils used to cook need to be washed with soap and water before they move on to your dish. They can’t cook cashew with chicken, dump it out, and then cook your chicken with broccoli and assume that it’s safe for someone with a nut allergy.”

Conventions, conferences, weddings and holiday parties present unique challenges for people with food allergies. Since eating elsewhere isn’t usually an option for guests at special events, ask if the event staff can prepare an alternative, allergy-safe meal. Clear and direct communication with the host or catering/banquet staff can prevent misunderstandings.

It’s also a good idea for people with food allergies to avoid buffets, since utensils are potentially shared and allergens can be easily transferred to another container.

Allergy & Asthma Network has created a customizable “Chef Card” that outlines the foods you must avoid when dining out. The diner then can present the card to the chef or manager for review. The “Chef Card” is part of the Network’s Allergy-Safe Dining guide, available as a free download.

“The bottom line is,” Dr. Stephanie Leonard said, “if you don’t feel comfortable at a restaurant or you don’t feel like the restaurant staff quite understands that your food allergy could be life-threatening, then the best choice is not to eat there.”

P.K. Daniel is a San Diego-based freelance writer. She is the mother of two children, Kayla and Camden. Kayla was diagnosed with asthma and food allergies when she was 2.

Reviewed by Andrea Holka and Michael Mellon, MD