ORIGINAL ARTICLE
Food allergy knowledge and aitude of restaurant personnel in Turkey Ayhan Sogut, MD1 , Ays¸e Bac¸c¸ıoglu ˘ Kavut, MD2 , I˙brahim Kartal, MD3 , Ercument Nazim Beyhun, MD4 , ¨ MD5 Atilla C¸ayır, MD5 , Mehmet Mutlu, MD3 and Behzat Ozkan,
Background: The incidence of food-induced allergic reactions is gradually increasing. Most of these allergic reactions occur in restaurants. Therefore, this study aims to investigate the awareness of restaurant personnel about food allergy.
them water to ‘dilute’ the allergen/Removing an allergen from a finished meal (eg, taking off nuts) may be all that is necessary to provide a safe meal for an allergic customer,” which measure food allergy knowledge levels, were 46.4%, 65.7%, 55.0%, and 65.7%, respectively.
Methods: The training, knowledge levels on food allergy, and comfort level in providing safe food of 351 restaurant personnel in Erzurum Province, Turkey, were assessed through a face-to-face survey.
Conclusion: According to our study, there are gaps in the food allergy knowledge of restaurant personnel. Because preparing and serving safe meals to patients with food allergy in restaurants is important, the training of restaurant C 2014 ARS-AAOA, personnel in food allergy is necessary.
Results: Among the participants, 81.5% were male (mean age 28.5 ± 8.5 years). Among them, 17.1% were chefs, 11.1% managers, 5.7% owners, and 66.1% waiters. Food allergy training was reported by 17.1% of the participants. The rates of restaurant personnel who gave the correct answers to the 4 questionnaire items, “Customers with food allergies can safely consume a small amount of that food/Food allergic reaction can cause death/If a customer is having an allergic reaction, it is appropriate to immediately serve
LLC.
F
ood allergy is a major health problem all over the world. The primary treatment of food allergy is to avoid the culprit foods. Reading the labels of manufactured food, knowing how to avoid cross-contact with allergens while preparing food, and having information about foods prepared at home, schools, camps, and restau1 Erzurum
Regional Training and Research Hospital, Department of Pediatric Allergy and Immunology, Erzurum, Turkey; 2 Erzurum Regional Training and Research Hospital, Department of Allergy and Immunology, Erzurum, Turkey; 3 Erzurum Regional Training and Research Hospital, Department of Pediatrics, Erzurum, Turkey; 4 Ataturk University, Medical Faculty, Department of Public Health, Erzurum, Turkey; 5 Ataturk University, Medical Faculty, Department of Pediatrics, Erzurum, Turkey
Correspondence to: I˙brahim Kartal, MD, Denizevler mahallesi 220. Sok, ˘ apt. No: 8/4 Atakum, Samsun, Turkey; e-mail: Sarıyigit [email protected] Potential conflict of interest: None provided. Received: 16 June 2014; Revised: 18 August 2014; Accepted: 26 August 2014 DOI: 10.1002/alr.21427 View this article online at wileyonlinelibrary.com.
157
International Forum of Allergy & Rhinology, Vol. 5, No. 2, February 2015
Key Words: allergy; food; restaurant; food allergy; training How to Cite this Article: Sogut A, Kavut AB, Kartal ˙I, et al. Food allergy knowledge and aitude of restaurant personnel in Turkey. Int Forum Allergy Rhinol. 2015;5:157-161.
rants are the main means of avoidance.1 People with food allergies should protect themselves from accidental exposure to allergic food because it may cause severe reactions and sometimes result in death.2 Food is an important cause of anaphylaxis.2 Bock et al.3 presented 31 cases of fatal food-induced anaphylaxis between 2001 and 2006. Deaths occurred in schools (3 cases), homes (12 cases), restaurants (8 cases), offices (4 cases), and camps (2 cases). Eigenmann and Zamora4 conducted an Internet-based survey of 51 patients with food allergies and found that 17.6% of the reported reactions occurred in restaurants. Among the 5149 registrants in the United States Peanut and Tree Nut Allergy Registry, 706 (13.7%) reported reactions occurring in restaurants and other food service establishments.5 In the present study, we assessed the knowledge levels of restaurant personnel about food allergy. A structured questionnaire was administered through a faceto-face interview to determine the responses of the subjects.
Sogut et al.
Materials and methods Study sample The study was carried out by using a questionnaire in Erzurum Province, in Eastern Turkey. Lists of restaurants in the city were obtained from the Erzurum Chamber of Tradesmen and Craftsmen. Erzurum has 207 table-service restaurants. The restaurants were randomly selected, and all workers from each restaurant were enrolled for this study.
Questionnaire The restaurant personnel were administered a questionnaire designed to measure their understanding of basic food allergy principles. The questionnaire was initially designed by Ahuja and Sicherer6 and then later developed by Bailey et al.7 We translated this questionnaire to Turkish. The questionnaire included 24 questions arranged as yes-or-no, true-or-false, or multiple-choice questions. One part of the questions was about the restaurant (ie, type of restaurant, number of food allergic emergencies in the past 3 years, and ability to respond to other dietary requests), and the other part was about the personnel (ie, age, years working in the food industry, current role, food safety and food allergy training, knowledge of food allergy, comfort level in dealing with customers with food allergy, and perceived training needs). An example of a question evaluating the food allergy knowledge of the participants is “Can you name for me 3 foods that commonly cause allergy?” The answer options to this question are “eggs/milk/peanuts/fish/soy/wheat/tree nuts.”
TABLE 1. Characteristics of the participants Feature
Demographics Male, n (%)
286 (81.5)
Age, years, mean ± SD
28.5 ± 8.5
Restaurant experience, years, median (minimum–maximum)
2 (0–38)
Responsibility of personnel, n (%) Chef
60 (17.1)
Manager
39 (11.1)
Owner
20 (5.7)
Waiter
232 (66.1)
SD = standard deviation.
Results The study included 82% (170) of the 207 table-service restaurants in the city. Among these, 17% (29) could not complete the questionnaire because of excessive workload or work policy. All participating restaurants were Turkish restaurants.
Demographic features of the participants A total of 351 individuals participated in the study. Most of the personnel were male, and the mean age was 28.5 ± 8.5 years. About 66.1% of the participants were waiters (Table 1).
Awareness of food allergy of the participants Data collection This survey study was carried out face-to-face in restaurants on the restaurant personnel, including chefs, managers, owners, and waiters. The interviewer was a ˙ physician (I.K.). All participants were informed about the study. Verbal consent of the participants was obtained.
Statistical analysis The descriptive statistics were presented as percentiles. The analysis of the interactions between nominal and ordinal variables was conducted by using the Pearson chi-square analysis. The association between the number of true answers and the type of service provider was determined by the chi-square for trend. Spearman correlation analysis was conducted to determine the correlation among age, year of experience, and number of true answers. Value of p less than 0.05 was considered statistically significant.
Ethical approval This study was approved by the Ethics Committee of Erzurum Regional Training and Research Hospital.
A total of 118 (33.6%) participants had received food hygiene training. Only 60 (17.1%) respondents had training about food allergy. Among these, 32 had attended a specific food allergy seminar, 5 had received education in school, and 3 had received training through television programs about food allergy. The remaining 20 did not explain how they had received training about food allergy. About 76% (269/351) of the participants wanted to obtain further training about food allergy. Among the participants, only one could define 2 symptoms of anaphylaxis. Only 10% of the participants reported that a food allergy emergency had occurred in the restaurant in the last 3 years (Table 2).
Knowledge about food allergy The results of the questions about food allergy knowledge are given in Table 3. The percentage of those who were able to recognize at least 3 allergens was 54.3%. Only 12.1% of the participants gave the correct answers to the true-or-false questions about food allergy (Table 3). The rate of correct answers to the 4 questions did not differ significantly among the participants (p > 0.05). The rate of correct answer was the highest among chefs (13.8%) and the lowest among managers (2.6%). Half of the
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Food allergy and restaurant personnel
TABLE 2. Features about food education and anaphylaxis of the participants Feature
n (%)
Food education Food hygiene education
118 (33.6)
Food allergy education
60 (17.1)
Desires further food allergy education
269 (76.6)
Knowledge of anaphylaxis Do you know what a person experiencing a food allergy reaction looks like? Yes
55 (15.8)
What does it look like? Able to define 2 features of anaphylactic emergency
1 (0.002)
participants answered correctly that customers with food allergies could safely consume a small amount of food to which they are allergic. Almost half of the participants stated correctly that if a customer was having an allergic reaction, they should be given cold water to dilute the
allergen. Two out of 3 participants correctly stated that a food allergic reaction could cause death. Two out of 3 participants reported correctly that removing an allergen from a finished meal, eg, removing nuts, might be all that is necessary to provide a safe meal for a customer with food
TABLE 3. Knowledge about food allergy of the participantsa Correct answers of personnel, count (%)b Manager (n = 39)
Waiter (n = 232)
Chef (n = 60)
Owner (n = 20)
Total (n = 351)
p
Customers with food allergies can safely consume a small amount of that food
14 (35.9)
119 (51.7)
21 (35.0)
8 (40.0)
349 (46.4)
0.05
A food allergy reaction can cause death
23 (59.0)
152 (66.4)
41 (69.5)
12 (60.0)
228 (65.7)
0.68
If a customer is having an allergic reaction they should be served cold water to dilute the allergen
18 (46.2)
131 (57.2)
30 (50.8)
12 (60.0)
191 (55.0)
0.51
Removing an allergen from a finished meal, eg, removing the nuts, may be all that is necessary to provide a safe meal for a food allergy customer
20 (51.3)
160 (69.9)
38 (64.4)
10 (50.0)
228 (65.7)
0.05
Egg
30 (76.9)
186 (80.2)
49 (81.7)
16 (80.0)
281 (80.1)
0.95
Milk
16 (41.0)
97 (42.0)
32 (53.3)
9 (45.0)
154 (44.0)
0.44
Peanut
12 (30.8)
62 (26.8)
14 (23.3)
11 (55.0)
99 (28.3)
0.04
Fish
17 (43.6)
85 (36.8)
27 (45.0)
7 (35.0)
136 (38.9)
0.60
Soybean
11 (28.2)
58 (25.0)
14 (23.3)
6 (30.0)
89 (25.4)
0.91
3 (7.7)
30 (12.9)
11 (18.3)
2 (10.0)
46 (13.1)
0.45
15 (38.5)
81 (34.9)
20 (33.3)
4 (20.0)
120 (34.2)
0.53
Questions
Selected foods as allergen
Wheat Nut-walnut a b
Values are n (%). Valid percent.
159
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Sogut et al.
FIGURE 1. Comfort level of the restaurant personnel in serving meals to customers with food allergy.
allergy (Table 3). The number of correct answers was not associated with age and restaurant experience (p = 0.5, p = 0.9, respectively).
Personnel’s comfort level in providing a safe meal to a customer with food allergy About 88% (308/351) of the participants expressed that they were comfortable serving a meal to a customer with food allergy, with 143 of these participants being “very comfortable” (Fig. 1). Knowledge about food allergy of the participants was not associated with comfort level in providing a safe meal (p = 0.2). No significant relationship was found among the responsibility of the personnel in the restaurant, their allergy training, and the reported comfort level in providing a safe meal (p = 0.7).
Discussion To the best of our knowledge, this study is the first comprehensive report that evaluated the knowledge level of restaurant personnel about food allergy in Turkey. The results showed that there are gaps in the knowledge and training in food allergy of restaurant personnel. Most of the respondents expressed that they were comfortable serving a meal to customer with food allergy. Knowledge about food allergy of the personnel was not associated with the comfort level in providing a safe meal. No significant relationship was found among the responsibility of the personnel in the restaurant, their allergy training, and the reported comfort level in providing a safe meal. Studies examining restaurant personnel’s awareness about food allergy is scarce. In Ahuja and Sicherer’s study6 using a telephone survey of 100 restaurant personnel, food allergy training was reported by 42% of the participants. In Bailey et al.’s study7 using a telephone survey of 90 restaurant personnel, 33% of the participants had food allergy
training. These studies showed that restaurant personnel had deficits in knowledge about food allergy. No association was found between comfort level in serving customers with food allergy and food allergy training in both studies. Although the restaurant personnel in these studies had a low level of knowledge about food allergy, they were comfortable in serving customers with food allergy. We conducted face-to-face interviews with 351 restaurant personnel from 170 restaurants. In our study, the rate of personnel who received training in food allergy, the restaurant personnel’s level of knowledge about food allergy, and the recognition rate of common allergens (eg, milk, peanuts, fish, wheat, and soy) were lower than those in previous studies.6, 7 The rate of personnel in our study who gave correct answers to the true-or-false questions about food allergy (4 questions) was only 12.1%, but the rate was 22% and 59% in Ahuja and Sicherer’s study6 and Bailey et al.’s study,7 respectively. The number of correct answers to the questions measuring food allergy knowledge was not associated with age and restaurant experience (p = 0.4, p = 0.8, respectively). The gaps in knowledge about food allergy, a life-threatening condition, and similarity of knowledge level about food allergy between old and new personnel suggested the urgent need for training. The belief that “restaurant meals are safe” may cause an increased risk of allergic reactions for patients. Recently published studies6, 7 have shown that, despite lack in food allergy knowledge, restaurant personnel were comfortable serving customers with food allergy. Moreover, no association was reported among the comfort level in serving customers with food allergy, food allergy training, and knowledge level of restaurant personnel.6, 7 Our results are similar to those obtained in previous studies. Our study has some limitations. First, a declaration-based questionnaire was used in this study, and no real-time monitoring or observation was made. Second, the study was conducted in 1 city only. More precise results can be obtained with multicentered and simultaneous studies.
Conclusion There are gaps in the food allergy knowledge of restaurant personnel. As preparing and serving safe meals to restaurant customers with food allergy are important, the training of restaurant personnel in food allergy may be useful for the customers with food allergy. The ingredients of all food served in restaurants should be clearly written in the menu. Measures to prevent cross-contamination during food preparation in the kitchen should be taken. Customers with food allergy should ensure that the food served in restaurant is safe. They should communicate clearly and directly to the restaurant personnel about their food allergy. Moreover, customers should pay attention to cross-contact and potential hidden ingredients. The waiter, cook, and customer should determine together whether the food can cause allergy or not.
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Acknowledgments We express our gratitude to Prof. Helen Smith and Dr. Samuel Bailey (Division of Public Health
and Primary ical School, support.
Care, Brighton and Sussex Falmer, Brighton, UK) for
Medtheir
References 1. Kim JS, Sicherer SH. Living with food allergy: allergen avoidance. Pediatr Clin North Am. 2011;58:459–470. 2. Simons FE, Ardusso LR, Bilo` MB, et al. World Allergy Organization. World allergy organization guidelines for the assessment and management of anaphylaxis. World Allergy Organ J. 2011;4:13–37. 3. Bock SA, Munoz-Furlong A, Sampson HA. Further fa˜ talities caused by anaphylactic reactions to food, 2001– 2006. J Allergy Clin Immunol. 2007;119:1016–1018.
4. Eigenmann PA, Zamora SA. An Internetbased survey on the circumstances of foodinduced reactions following the diagnosis of IgE-mediated food allergy. Allergy. 2002;57: 449–453. 5. Furlong TJ, De Simone J, Sicherer SH. Peanut and treenut allergic reactions in restaurants and other food establishments. J Allergy Clin Immunol. 2001;108:867–870.
6. Ahuja R, Sicherer SH. Food-allergy management from the perspective of restaurant and food establishment personnel. Ann Allergy Asthma Immunol. 2007;98: 344–348. 7. Bailey S, Albardiaz R, Frew AJ, Smith H. Restaurant staff’s knowledge of anaphylaxis and dietary care of people with allergies. Clin Exp Allergy. 2011;41:713– 717.
UPCOMING MEETING ANNOUNCEMENT 2015 The University of Pennsylvania will host its 7th International Otolaryngology Update Course at the Santa Barbara Resort, Curacao, Dutch Antilles, November 3–6, 2015. For additional information please email [email protected] or visit the website at http://www.uphs.upenn.edu/pennorl/education/cme.html
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International Forum of Allergy & Rhinology, Vol. 5, No. 2, February 2015
Food allergy knowledge and aitude of restaurant personnel in Turkey Ayhan Sogut, MD1 , Ays¸e Bac¸c¸ıoglu ˘ Kavut, MD2 , I˙brahim Kartal, MD3 , Ercument Nazim Beyhun, MD4 , ¨ MD5 Atilla C¸ayır, MD5 , Mehmet Mutlu, MD3 and Behzat Ozkan,
Background: The incidence of food-induced allergic reactions is gradually increasing. Most of these allergic reactions occur in restaurants. Therefore, this study aims to investigate the awareness of restaurant personnel about food allergy.
them water to ‘dilute’ the allergen/Removing an allergen from a finished meal (eg, taking off nuts) may be all that is necessary to provide a safe meal for an allergic customer,” which measure food allergy knowledge levels, were 46.4%, 65.7%, 55.0%, and 65.7%, respectively.
Methods: The training, knowledge levels on food allergy, and comfort level in providing safe food of 351 restaurant personnel in Erzurum Province, Turkey, were assessed through a face-to-face survey.
Conclusion: According to our study, there are gaps in the food allergy knowledge of restaurant personnel. Because preparing and serving safe meals to patients with food allergy in restaurants is important, the training of restaurant C 2014 ARS-AAOA, personnel in food allergy is necessary.
Results: Among the participants, 81.5% were male (mean age 28.5 ± 8.5 years). Among them, 17.1% were chefs, 11.1% managers, 5.7% owners, and 66.1% waiters. Food allergy training was reported by 17.1% of the participants. The rates of restaurant personnel who gave the correct answers to the 4 questionnaire items, “Customers with food allergies can safely consume a small amount of that food/Food allergic reaction can cause death/If a customer is having an allergic reaction, it is appropriate to immediately serve
LLC.
F
ood allergy is a major health problem all over the world. The primary treatment of food allergy is to avoid the culprit foods. Reading the labels of manufactured food, knowing how to avoid cross-contact with allergens while preparing food, and having information about foods prepared at home, schools, camps, and restau1 Erzurum
Regional Training and Research Hospital, Department of Pediatric Allergy and Immunology, Erzurum, Turkey; 2 Erzurum Regional Training and Research Hospital, Department of Allergy and Immunology, Erzurum, Turkey; 3 Erzurum Regional Training and Research Hospital, Department of Pediatrics, Erzurum, Turkey; 4 Ataturk University, Medical Faculty, Department of Public Health, Erzurum, Turkey; 5 Ataturk University, Medical Faculty, Department of Pediatrics, Erzurum, Turkey
Correspondence to: I˙brahim Kartal, MD, Denizevler mahallesi 220. Sok, ˘ apt. No: 8/4 Atakum, Samsun, Turkey; e-mail: Sarıyigit [email protected] Potential conflict of interest: None provided. Received: 16 June 2014; Revised: 18 August 2014; Accepted: 26 August 2014 DOI: 10.1002/alr.21427 View this article online at wileyonlinelibrary.com.
157
International Forum of Allergy & Rhinology, Vol. 5, No. 2, February 2015
Key Words: allergy; food; restaurant; food allergy; training How to Cite this Article: Sogut A, Kavut AB, Kartal ˙I, et al. Food allergy knowledge and aitude of restaurant personnel in Turkey. Int Forum Allergy Rhinol. 2015;5:157-161.
rants are the main means of avoidance.1 People with food allergies should protect themselves from accidental exposure to allergic food because it may cause severe reactions and sometimes result in death.2 Food is an important cause of anaphylaxis.2 Bock et al.3 presented 31 cases of fatal food-induced anaphylaxis between 2001 and 2006. Deaths occurred in schools (3 cases), homes (12 cases), restaurants (8 cases), offices (4 cases), and camps (2 cases). Eigenmann and Zamora4 conducted an Internet-based survey of 51 patients with food allergies and found that 17.6% of the reported reactions occurred in restaurants. Among the 5149 registrants in the United States Peanut and Tree Nut Allergy Registry, 706 (13.7%) reported reactions occurring in restaurants and other food service establishments.5 In the present study, we assessed the knowledge levels of restaurant personnel about food allergy. A structured questionnaire was administered through a faceto-face interview to determine the responses of the subjects.
Sogut et al.
Materials and methods Study sample The study was carried out by using a questionnaire in Erzurum Province, in Eastern Turkey. Lists of restaurants in the city were obtained from the Erzurum Chamber of Tradesmen and Craftsmen. Erzurum has 207 table-service restaurants. The restaurants were randomly selected, and all workers from each restaurant were enrolled for this study.
Questionnaire The restaurant personnel were administered a questionnaire designed to measure their understanding of basic food allergy principles. The questionnaire was initially designed by Ahuja and Sicherer6 and then later developed by Bailey et al.7 We translated this questionnaire to Turkish. The questionnaire included 24 questions arranged as yes-or-no, true-or-false, or multiple-choice questions. One part of the questions was about the restaurant (ie, type of restaurant, number of food allergic emergencies in the past 3 years, and ability to respond to other dietary requests), and the other part was about the personnel (ie, age, years working in the food industry, current role, food safety and food allergy training, knowledge of food allergy, comfort level in dealing with customers with food allergy, and perceived training needs). An example of a question evaluating the food allergy knowledge of the participants is “Can you name for me 3 foods that commonly cause allergy?” The answer options to this question are “eggs/milk/peanuts/fish/soy/wheat/tree nuts.”
TABLE 1. Characteristics of the participants Feature
Demographics Male, n (%)
286 (81.5)
Age, years, mean ± SD
28.5 ± 8.5
Restaurant experience, years, median (minimum–maximum)
2 (0–38)
Responsibility of personnel, n (%) Chef
60 (17.1)
Manager
39 (11.1)
Owner
20 (5.7)
Waiter
232 (66.1)
SD = standard deviation.
Results The study included 82% (170) of the 207 table-service restaurants in the city. Among these, 17% (29) could not complete the questionnaire because of excessive workload or work policy. All participating restaurants were Turkish restaurants.
Demographic features of the participants A total of 351 individuals participated in the study. Most of the personnel were male, and the mean age was 28.5 ± 8.5 years. About 66.1% of the participants were waiters (Table 1).
Awareness of food allergy of the participants Data collection This survey study was carried out face-to-face in restaurants on the restaurant personnel, including chefs, managers, owners, and waiters. The interviewer was a ˙ physician (I.K.). All participants were informed about the study. Verbal consent of the participants was obtained.
Statistical analysis The descriptive statistics were presented as percentiles. The analysis of the interactions between nominal and ordinal variables was conducted by using the Pearson chi-square analysis. The association between the number of true answers and the type of service provider was determined by the chi-square for trend. Spearman correlation analysis was conducted to determine the correlation among age, year of experience, and number of true answers. Value of p less than 0.05 was considered statistically significant.
Ethical approval This study was approved by the Ethics Committee of Erzurum Regional Training and Research Hospital.
A total of 118 (33.6%) participants had received food hygiene training. Only 60 (17.1%) respondents had training about food allergy. Among these, 32 had attended a specific food allergy seminar, 5 had received education in school, and 3 had received training through television programs about food allergy. The remaining 20 did not explain how they had received training about food allergy. About 76% (269/351) of the participants wanted to obtain further training about food allergy. Among the participants, only one could define 2 symptoms of anaphylaxis. Only 10% of the participants reported that a food allergy emergency had occurred in the restaurant in the last 3 years (Table 2).
Knowledge about food allergy The results of the questions about food allergy knowledge are given in Table 3. The percentage of those who were able to recognize at least 3 allergens was 54.3%. Only 12.1% of the participants gave the correct answers to the true-or-false questions about food allergy (Table 3). The rate of correct answers to the 4 questions did not differ significantly among the participants (p > 0.05). The rate of correct answer was the highest among chefs (13.8%) and the lowest among managers (2.6%). Half of the
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Food allergy and restaurant personnel
TABLE 2. Features about food education and anaphylaxis of the participants Feature
n (%)
Food education Food hygiene education
118 (33.6)
Food allergy education
60 (17.1)
Desires further food allergy education
269 (76.6)
Knowledge of anaphylaxis Do you know what a person experiencing a food allergy reaction looks like? Yes
55 (15.8)
What does it look like? Able to define 2 features of anaphylactic emergency
1 (0.002)
participants answered correctly that customers with food allergies could safely consume a small amount of food to which they are allergic. Almost half of the participants stated correctly that if a customer was having an allergic reaction, they should be given cold water to dilute the
allergen. Two out of 3 participants correctly stated that a food allergic reaction could cause death. Two out of 3 participants reported correctly that removing an allergen from a finished meal, eg, removing nuts, might be all that is necessary to provide a safe meal for a customer with food
TABLE 3. Knowledge about food allergy of the participantsa Correct answers of personnel, count (%)b Manager (n = 39)
Waiter (n = 232)
Chef (n = 60)
Owner (n = 20)
Total (n = 351)
p
Customers with food allergies can safely consume a small amount of that food
14 (35.9)
119 (51.7)
21 (35.0)
8 (40.0)
349 (46.4)
0.05
A food allergy reaction can cause death
23 (59.0)
152 (66.4)
41 (69.5)
12 (60.0)
228 (65.7)
0.68
If a customer is having an allergic reaction they should be served cold water to dilute the allergen
18 (46.2)
131 (57.2)
30 (50.8)
12 (60.0)
191 (55.0)
0.51
Removing an allergen from a finished meal, eg, removing the nuts, may be all that is necessary to provide a safe meal for a food allergy customer
20 (51.3)
160 (69.9)
38 (64.4)
10 (50.0)
228 (65.7)
0.05
Egg
30 (76.9)
186 (80.2)
49 (81.7)
16 (80.0)
281 (80.1)
0.95
Milk
16 (41.0)
97 (42.0)
32 (53.3)
9 (45.0)
154 (44.0)
0.44
Peanut
12 (30.8)
62 (26.8)
14 (23.3)
11 (55.0)
99 (28.3)
0.04
Fish
17 (43.6)
85 (36.8)
27 (45.0)
7 (35.0)
136 (38.9)
0.60
Soybean
11 (28.2)
58 (25.0)
14 (23.3)
6 (30.0)
89 (25.4)
0.91
3 (7.7)
30 (12.9)
11 (18.3)
2 (10.0)
46 (13.1)
0.45
15 (38.5)
81 (34.9)
20 (33.3)
4 (20.0)
120 (34.2)
0.53
Questions
Selected foods as allergen
Wheat Nut-walnut a b
Values are n (%). Valid percent.
159
International Forum of Allergy & Rhinology, Vol. 5, No. 2, February 2015
Sogut et al.
FIGURE 1. Comfort level of the restaurant personnel in serving meals to customers with food allergy.
allergy (Table 3). The number of correct answers was not associated with age and restaurant experience (p = 0.5, p = 0.9, respectively).
Personnel’s comfort level in providing a safe meal to a customer with food allergy About 88% (308/351) of the participants expressed that they were comfortable serving a meal to a customer with food allergy, with 143 of these participants being “very comfortable” (Fig. 1). Knowledge about food allergy of the participants was not associated with comfort level in providing a safe meal (p = 0.2). No significant relationship was found among the responsibility of the personnel in the restaurant, their allergy training, and the reported comfort level in providing a safe meal (p = 0.7).
Discussion To the best of our knowledge, this study is the first comprehensive report that evaluated the knowledge level of restaurant personnel about food allergy in Turkey. The results showed that there are gaps in the knowledge and training in food allergy of restaurant personnel. Most of the respondents expressed that they were comfortable serving a meal to customer with food allergy. Knowledge about food allergy of the personnel was not associated with the comfort level in providing a safe meal. No significant relationship was found among the responsibility of the personnel in the restaurant, their allergy training, and the reported comfort level in providing a safe meal. Studies examining restaurant personnel’s awareness about food allergy is scarce. In Ahuja and Sicherer’s study6 using a telephone survey of 100 restaurant personnel, food allergy training was reported by 42% of the participants. In Bailey et al.’s study7 using a telephone survey of 90 restaurant personnel, 33% of the participants had food allergy
training. These studies showed that restaurant personnel had deficits in knowledge about food allergy. No association was found between comfort level in serving customers with food allergy and food allergy training in both studies. Although the restaurant personnel in these studies had a low level of knowledge about food allergy, they were comfortable in serving customers with food allergy. We conducted face-to-face interviews with 351 restaurant personnel from 170 restaurants. In our study, the rate of personnel who received training in food allergy, the restaurant personnel’s level of knowledge about food allergy, and the recognition rate of common allergens (eg, milk, peanuts, fish, wheat, and soy) were lower than those in previous studies.6, 7 The rate of personnel in our study who gave correct answers to the true-or-false questions about food allergy (4 questions) was only 12.1%, but the rate was 22% and 59% in Ahuja and Sicherer’s study6 and Bailey et al.’s study,7 respectively. The number of correct answers to the questions measuring food allergy knowledge was not associated with age and restaurant experience (p = 0.4, p = 0.8, respectively). The gaps in knowledge about food allergy, a life-threatening condition, and similarity of knowledge level about food allergy between old and new personnel suggested the urgent need for training. The belief that “restaurant meals are safe” may cause an increased risk of allergic reactions for patients. Recently published studies6, 7 have shown that, despite lack in food allergy knowledge, restaurant personnel were comfortable serving customers with food allergy. Moreover, no association was reported among the comfort level in serving customers with food allergy, food allergy training, and knowledge level of restaurant personnel.6, 7 Our results are similar to those obtained in previous studies. Our study has some limitations. First, a declaration-based questionnaire was used in this study, and no real-time monitoring or observation was made. Second, the study was conducted in 1 city only. More precise results can be obtained with multicentered and simultaneous studies.
Conclusion There are gaps in the food allergy knowledge of restaurant personnel. As preparing and serving safe meals to restaurant customers with food allergy are important, the training of restaurant personnel in food allergy may be useful for the customers with food allergy. The ingredients of all food served in restaurants should be clearly written in the menu. Measures to prevent cross-contamination during food preparation in the kitchen should be taken. Customers with food allergy should ensure that the food served in restaurant is safe. They should communicate clearly and directly to the restaurant personnel about their food allergy. Moreover, customers should pay attention to cross-contact and potential hidden ingredients. The waiter, cook, and customer should determine together whether the food can cause allergy or not.
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Acknowledgments We express our gratitude to Prof. Helen Smith and Dr. Samuel Bailey (Division of Public Health
and Primary ical School, support.
Care, Brighton and Sussex Falmer, Brighton, UK) for
Medtheir
References 1. Kim JS, Sicherer SH. Living with food allergy: allergen avoidance. Pediatr Clin North Am. 2011;58:459–470. 2. Simons FE, Ardusso LR, Bilo` MB, et al. World Allergy Organization. World allergy organization guidelines for the assessment and management of anaphylaxis. World Allergy Organ J. 2011;4:13–37. 3. Bock SA, Munoz-Furlong A, Sampson HA. Further fa˜ talities caused by anaphylactic reactions to food, 2001– 2006. J Allergy Clin Immunol. 2007;119:1016–1018.
4. Eigenmann PA, Zamora SA. An Internetbased survey on the circumstances of foodinduced reactions following the diagnosis of IgE-mediated food allergy. Allergy. 2002;57: 449–453. 5. Furlong TJ, De Simone J, Sicherer SH. Peanut and treenut allergic reactions in restaurants and other food establishments. J Allergy Clin Immunol. 2001;108:867–870.
6. Ahuja R, Sicherer SH. Food-allergy management from the perspective of restaurant and food establishment personnel. Ann Allergy Asthma Immunol. 2007;98: 344–348. 7. Bailey S, Albardiaz R, Frew AJ, Smith H. Restaurant staff’s knowledge of anaphylaxis and dietary care of people with allergies. Clin Exp Allergy. 2011;41:713– 717.
UPCOMING MEETING ANNOUNCEMENT 2015 The University of Pennsylvania will host its 7th International Otolaryngology Update Course at the Santa Barbara Resort, Curacao, Dutch Antilles, November 3–6, 2015. For additional information please email [email protected] or visit the website at http://www.uphs.upenn.edu/pennorl/education/cme.html
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