Food Protection Trends, Vol. 32, No. 12, Pages 736–746 Copyright© 2012, International Association for Food Protection ARTICLES 6200 Aurora Ave., Suite 200W, Des Moines, IA 50322-2864 Exploration of Past Exper- iences, Attitudes and Pre- ventive Behaviors of Consumers with Food Allergies about Dining Out: A Focus Group Study JUNEHEE KWON1* and YEE MING LEE2 1Dept. of Hospitality Management and Dietetics, Kansas State University, 108 Justin Hall, Manhattan, KS 66506, USA; 2Dept. of Nutrition, Dietetics, and Hospitality Management, Auburn University, 328 Spindle Hall, Auburn, AL 36849, USA SUMMARY This study investigated the attitudes and behaviors of consumers with food allergies toward dining out. Four focus groups with 17 individuals with food allergies were conducted to learn about their dining experiences. All sessions were audio-recorded, transcribed verbatim, and organized for extracting key concepts. Eight participants experienced allergic reactions after dining out at the restaurants, and many had unpleasant experiences when dining out. Participants perceived cross- contact, hidden ingredients, and miscommunication as potential causes of food allergic reactions. Participants identified lack of training, awareness, and knowledge about food allergy, and other operational restrictions such as lack of resources, as barriers to providing allergen-free food in restaurants. Buffet, ethnic, and specialty restaurants were seen as high-risk dining places due to potential risks of cross-contacts and hidden allergens in sauces. The participants took various precautions such as asking for clarifications of ingredients and seeking restaurants that are familiar to them. Consumers with food allergies experienced many difficulties in restaurants due to restaurant employees’ lack of knowledge and training regarding food allergy. Through qualitative research, this study provides an in-depth understanding of the difficulties faced by consumers with food allergies, and addresses future training needs for restaurateurs to accommodate their clients with food allergies. A peer-reviewed article *Author for correspondence: Phone: +1 785.532.5369; Fax: +1 785.532.5522 E-mail: [email protected] 736 FOOD PROTECTION TRENDS | DECEMBER 2012 INTRODUCTION take preventive measures (15, 16). Entry- viewpoint of consumers with food al- level foodservice staff often lacks formal lergies, what contributing factors led to Food allergies affect 15 million training (6), but only 55% of restaurants food allergic reactions? (c) What types of adults as well as six million children un- (n = 85) that participated in a survey in- restaurants are preferred by consumers der 18 years of age in the U.S. (12, 20). dicated they had food allergy guidelines with food allergies? (d) What preventive Providing allergen-free food to clients in place (9). Barriers to food allergy train- actions have individuals with food al- with food allergies is increasingly chall- ing included high training cost, high staff lergies or parents of children with food enging as the prevalence of food allergies turnover, time constraints, language bar- allergies taken? (e) What do consum- continues to increase (12). Symptoms of riers, and lack of interest by management ers with food allergies expect from res- food allergies range from mild, such as and employees (1). taurateurs in terms of accommodating skin rashes, to anaphylactic shock, the The legal environment of food al- their needs? The results of the study may most severe allergic response and a lead- lergies is changing for restaurants in provide increased understanding of how ing cause of emergency room visits and line with the effort to raise awareness of consumers with food allergies feel about 100–200 deaths yearly (32). Since there food allergies among restaurant opera- dining out and suggestions for restaurant is no cure for food allergies, stringent tors (13). States such as New York, Con- operators to better understand the needs avoidance of allergens is the only way to necticut, Massachusetts, Illinois, Rhode of their clients with food allergies, as well prevent food allergic reactions (12). Island, and Pennsylvania have mandated as providing the basis for development of In addition to their life-threatening that at least one employee with food al- a questionnaire for a quantitative survey nature, food allergies also have some lergy knowledge be present during food study. psychological and societal impacts on production and service (13). The Food children with food allergies. Children Labeling and Consumer Protection Act METHODS with food allergies have been reported (FLCPA) of 2004 mandates that manu- to be bullied, mocked, or harassed by facturers clearly identify on food labels Focus group discussion was used for their peers (27). Moreover, food allergies any of the eight major food allergens data collection, as this study was con- impose some emotional reactions such and/or their protein derivatives in the ducted in an exploratory manner. Focus as fear, guilt, and anxiety on parents of food (41). The Food and Drug Admin- groups allowed researchers to explore in children with food allergies (42). Fami- istration (FDA) recommends through depth consumers’ perspectives about din- lies also face challenges related to their Food Code 2009 that allergy education ing out with food allergies. In addition, children attending schools, eating at res- be a part of food safety training for food- focus groups capture a wide spectrum of taurants, and traveling (19, 31). service employees (14). opinions and give participants an oppor- Food allergic reactions may occur Several studies have investigated the tunity to engage in an open discussion in many places, but commercial restau- causes of food allergic reactions in res- in a comfortable and permissive setting rants are common places for such reac- taurants, as well as the knowledge and (21, 24). tions to occur. Wanich, Weiss, Furlong, attitudes of restaurateurs toward food and Sicherer (45) reported that, of 294 allergies (3, 5, 29). Cross-contact, an ac- participants who attended a conference Recruitment of focus group cidental exposure to food allergens when organized by the Food Allergy and Ana- participants “one food comes into contact with an- phylaxis Network (FAAN), 34% had ex- other causing their proteins to mix (10)” Research protocols were approved perienced at least one, and another 36% and hidden allergens in mixed dishes and by a university Institutional Review had experienced at least three, reactions sauces were two major causes of food Board prior to data collection. To be eli- related to dining at restaurants. Further- allergic reactions (27, 37). However, re- gible for the study, participants had to be more, Pumphrey (35) found that 76% of search about the attitudes (e.g., perceived adults (≥ 18 years old) allergic to at least deaths caused by food allergies occurred causes of food allergic reactions and bar- one food item, or parents/guardians of a after meals were consumed outside of the riers to providing allergen-free food) dependent with food allergies. A medical home. Another analysis of food allergic- and behaviors (e.g., preventive measures doctor’s confirmation of food allergy di- related fatalities indicated that 29 of 63 taken and types of restaurants avoided) agnosis was not required to participate in of these cases were caused by food eaten related to dining out of consumers with the study, as it was beyond the scope of in a restaurant (45). food allergies is limited. In addition, the this research project. To ensure that only Some restaurant operators thought responsibilities of restaurateurs in serving relevant data were collected, only those that customers should inform them customers with food allergies needs to be who dined out at least once a month at about their food allergies (1, 34). Diners, further investigated. Therefore, the pur- commercial restaurants were eligible to however, may assume that food is safe if pose of this study was to explore the at- participate in this study. allergens are not listed on the menu (4). titudes and behaviors of consumers with Recruitment flyers were posted in These mismatched expectations may re- food allergies toward dining out, using a selected ���������������������������������public places��������������������, such as local gro- sult in food allergic reactions in restau- focus group approach. cery stores, in a mid-sized city in Kansas, rants. However, customers with food al- The specific research questions this after permission had been received from lergies have said they would not reduce study addressed were (a) What are the the facility management. Flyers were also the frequency of dining out even after past dining experiences of consumers posted on the bulletin boards of all of the allergic reactions, although they would affected by food allergies? (b) From the colleges at a Midwestern university. The DECEMBER 2012 | FOOD PROTECTION TRENDS 737 TABLE 1. Demographic characteristics of food allergy focus group participants (n = 17) Characteristics No. (%) Mean (Range) Gender 2 (11.8) Male 15 (88.2) Female Age, years 32.3 (21–59) Types of Food Allergensa Peanuts 3 (11.1) Tree Nuts 3 (11.1) Seafood 2 (7.4) Shellfish 2 (7.4) Wheat 1 (3.7) Soy 1 (3.7) Fruits 5 (18.5) Others 10 (37.1) Frequency of dining out At least once a week 10 (58.8) 2–3 times a month 5 (29.4) About once a month 1 (5.9) Less than once a month 1 (5.9) Experiencing food allergic reactions in commercial restaurants Yes 8 (47.1) No 9 (52.9) Past experience working at a restaurant Yes 13 (76.5) No 4 (23.5) Length of work at a restaurant, months 23.2 (2–48) aSome participants indicated more than one kind of food allergens flyer included eligibility requirements, confidentiality and the voluntary nature food allergy research experience as well information on participant compensa- of participation������������������������ �����������������������before signing the con- as from questions asked by Gupta et al. tion ($20 cash), and the researchers’ con- sent form. Before each session, partici- (19). Participants were encouraged to ex- tact information.