by Chrissy Carroll, MPH, RD 1 HOUR CE CBDM Approved SAN When Doesn’t Do a Body Good Handling Allergies and Intolerances

FOOD PROTECTION CONNECTION

In any type of foodservice setting—from schools to TYPES OF DAIRY ALLERGIES AND long-term care—you’ll likely encounter people with dairy INTOLERANCES allergies or intolerances. While many recognize that nuts The first step to understanding necessary modifications is can cause life-threatening reactions among those with to understand the specific condition. There are six types of allergies, it can be hard to grasp that dairy allergies are just dairy allergies or intolerances that you may come across: as serious. 1. Milk/Dairy Allergy Adding to the confusion are the numerous types of dairy allergies and intolerances. Some are severe and require Condition: A food allergy occurs when the body’s complete avoidance of any dairy ingredient, while others immune system reacts to the otherwise harmless proteins may justify avoiding certain types of dairy. in foods. In the case of a dairy allergy, the body produces IgE (immunoglobulin E) antibodies designed to “fight” the By brushing up on these conditions and learning milk proteins. precautions for each, you can better understand and nourish your clients while preventing life-threatening reactions.

8 NUTRITION & FOODSERVICE EDGE | May-June 2019 [email protected]

In producing these IgE antibodies. However, it still trigger food for FPIES is Chrissy Carroll, MPH, antibodies, the body also triggers an immune system dairy. RD is a registered releases chemicals that response (thought to occur dietitian, freelance Symptoms: Approximately cause an allergic response at the cellular level instead). writer, and brand one to four hours after a consultant based in and various symptoms. Symptoms: child ingests the trigger central Massachusetts. Some people may have foods, they experience mild allergies while others • Mucous and/or blood in intense repetitive vomiting can have a life-threatening the stool and diarrhea which can lead reaction. • Abdominal discomfort to dehydration and even Symptoms: • Colic shock. • Fussiness • Hives Population: Most • Itchy mouth • Eczema commonly diagnosed in • Nausea Population: Diagnosed infants and young children. Most children with FPIES • Vomiting in infancy, so you’re more likely to see it in hospital outgrow it around school- • Diarrhea settings. Many children age. You may encounter • Trouble swallowing will outgrow the condition children with this condition • Wheezing between one to three years in hospitals and school • Passing out of age. However, some settings. children will not—so if you • Chest pain Continued on page 10 work in a school setting, • Drop in blood pressure you may see children with • Swelling of the throat this condition. • Anaphylaxis (severe life- Dietary Modifications: Brush up on threatening reaction that Complete elimination of can occur within minutes) any type of or precautions to Population: Any age ingredient. If the infant is (though more common , the mother help prevent among children) – so you’re will need to eliminate life-threatening likely to see it across work all dairy from her diet. If settings. formula fed, the family can reactions to dairy switch to a hypoallergenic Dietary Modifications: or elemental formula. If Complete elimination of the condition persists into any type of dairy product or childhood, the child must ingredient. follow a dairy-free diet.

2. Non-IgE Mediated 3. Food Protein- Cow’s Milk Protein Induced Enterocolitis Allergy Syndrome (FPIES) Condition: Unlike a Condition: This is another traditional allergy with type of non-IgE mediated an IgE response, this is food allergy, and quite an allergy that does not severe. The most common cause production of IgE

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Dietary Modifications: Dietary Modifications: Symptoms: Complete elimination of Individualized. People with • Gas any type of dairy product or lactose intolerance may • Stomach discomfort ingredient. Similar to above, be able to tolerate certain this may affect an infant’s forms of dairy, as different • Bloating formula, a breastfeeding products contain varying • Diarrhea mother’s diet, or an older amounts of lactose. There Population: Any age—so child’s diet. are also specialty milk you could encounter in any products on the market work setting. 4. Lactose Intolerance where lactose is already Condition: The individual broken down, making it Dietary Modifications: does not produce enough easier to digest. Select an alternative to lactase, an enzyme needed regular milk—either a non- to break down lactose (the 5. Sensitivity to A1 dairy alternative, or a dairy form of found in dairy Beta-Casein product made solely with products). As such, the Condition: There is A2 beta-casein. The latter is RESEARCHERS lactose sugar is not broken emerging (though not not a dairy alternative, but is BELIEVE instead sourced from select down in the small intestine conclusive) evidence that certain cases of self- like it normally would be. It certain people may have breeds of cows that only instead travels to the large a sensitivity to a protein produce the A2 beta-casein diagnosed lactose intestine where in called A1 beta-casein in protein in their milk. intolerance may not the body start to break it cow’s milk. 6. Self-Reported be related to the down, causing discomfort. Traditional dairy milk Dairy Intolerance or lactose, but to A1 While lactose intolerance contains several different Avoidance beta-casein protein. causes uncomfortable types of casein proteins. Condition: The individual symptoms, it is not life The two most common are reports they are intolerant threatening like an allergy. A1 beta-casein and A2 beta- to dairy and/or that they casein. A few recent studies Symptoms: wish to avoid it, but there have shown that A1 may • Gas is no official medical cause more digestive upset diagnosis. • Stomach discomfort compared to A2. • Bloating This is a bit of a catch-all Researchers believe bucket. The condition • Diarrhea that certain cases of could be related to Population: All ages. self-diagnosed lactose gastrointestinal side effects However, since lactase intolerance may in fact not they’ve experienced in the production can decline over be related to the lactose, but past—and as such, there time, it’s likely that you’ll rather that A1 beta-casein may in fact be a true issue see a greater proportion of protein. Keep in mind this like lactose intolerance or a older adults with lactose is very new research, so it’s sensitivity to the A1 beta- intolerance in long-term not definitive. However, casein protein. It could also care settings. it’s wise to be aware of it be an undiagnosed non- in case you come across a IgE mediated allergy with client that reports this issue. very mild responses, like eczema.

10 NUTRITION & FOODSERVICE EDGE | May-June 2019 On the flip side, they may have simply decided to avoid Handling dairy allergies, non-IgE mediated cow’s dairy based on input from family, friends, the media, or milk protein allergy, or FPIES: misconceptions about dairy products. For these issues, complete elimination of all dairy products Symptoms: Vary widely. and ingredients is necessary – and consequences of accidental ingestion are much more severe. Population: All ages, though more common among adults. Become an allergen-aware kitchen. • Prevent cross-contamination by frequently washing Dietary Modifications: In self-reported intolerances, a hands, changing gloves, and cleaning surfaces. nutrition interview can help you learn more about what the patient does not tolerate or enjoy. You can work to adjust • Ensure that foods are clearly labeled in-storage with meals from there. A consult with an RD can also be very potential allergens. helpful for further understanding the patient’s issues. • Always check product labels when opening a new package. Even if the product was previously safe, FOODSERVICE PRECAUTIONS manufacturers change formulations frequently. FOR DAIRY ALLERGIES AND I N T O L E R A N C E S • Don’t assume a food is naturally dairy free. Some surprising sources of dairy include certain salad People with food allergies or intolerances put a lot of dressings, pasta sauces, flavored chips, instant potatoes, trust in foodservice staff to prepare safe meals. Once or hot dogs. you’re aware of a client’s condition, you can implement • Label potential allergens on the serving line. appropriate modifications. Here are some tips: • Use separate utensils for serving each item. Handling lactose intolerance, A1 sensitivity, or • Remember that a dairy ingredient cannot simply be mild self-reported intolerance: removed if it is mistakenly put on or in an item. For • Interview clients. Chat with them about which dairy example, a slice of cannot be taken off a sandwich products they can and can’t tolerate. For example, some and served to an allergic resident or student. The order people with lactose intolerance can on must be remade, as small amounts of allergens can cause comfortably, but can’t chug a tall glass of milk. Similarly, a severe reaction. some people with self-reported intolerances may tolerate Modify meals. dairy that’s baked into products, but perceive discomfort with fresh dairy. • Add meals to your menu plan which can easily be modified to a dairy-free option. For example, the • Offer alternatives. Consider keeping different shredded cheddar on top of a bowl of chili could simply variations of traditional cow’s milk on hand, like lactose- be left off, or sauce on pasta could be swapped for free dairy milk. Or, consider keeping calcium-fortified plain red sauce. dairy alternatives on hand, like . Product selection will depend on the number of clients with • Use olive oil for sautéing vegetables and meats, rather particular issues, cost-effectiveness of products, other than . medical conditions, nutritional needs, and applicable • For products like salad dressings and pasta sauces, regulations for your foodservice setting. There is no one choose versions that are already dairy free which can be “right” choice. used for everyone. • Communicate clearly. If there is a serving line for • Offer calcium-fortified dairy alternatives as it fits your students or residents to grab food, label foods with program’s requirements and budget. potential allergens, including dairy. Similarly, ensure staff • In a hospital setting where cases of FPIES or non-IgE is available to answer questions about whether dairy is mediated cow’s milk protein allergy are seen, offer dairy- present in a dish. Though the conditions in this section free meal options for the breastfeeding mother. are not life-threatening, this will help people to make their own informed decisions based on their personal needs. Continued on page 12

NUTRITION & FOODSERVICE EDGE | May-June 2019 11 Continued from page 11 Ingredients to Avoid for Dairy Allergies

Avoiding dairy means more than just skipping the milk, cheese, and yogurt. Many processed foods unexpectedly include dairy. While manufacturers are legally required to identify allergens in plain language on labels, you may Be prepared. encounter a label that is not compliant. Use this list to help you identify dairy ingredients in a • Ensure back-of-the-house and front-of-the-house are product. familiar with allergen awareness. They should either understand how to communicate potential allergens, or Artificial butter flavor Lactalbumin know who the person-in-charge is to ask about potential Artificial cheese Lactate solids allergens. flavor Lactoglobulin • Create a food allergy plan that outlines all steps to Butter Lactose prevent reactions—as well as what to do in emergencies. Lactulose Train your staff on these procedures. Remember, an Casein Milk (and any variation anaphylactic reaction can start in just minutes. Caseinate (including of this, including calcium caseinate, , SPECIFIC CONSIDERATIONS FOR potassium caseinate, milk solids, dry milk SCHOOL NUTRITION PROGRAMS and any other version) powder, etc.) According to the Centers for Disease Control and Cheese (including Nougat Prevention (CDC), 20 percent of children with food cottage cheese, cream Paneer allergies will have a reaction to a food while at school. It’s cheese, cheddar Pudding essential that all foodservice staff put their utmost effort cheese, etc.) into preventing allergic reactions. Cream Children with food allergies have legal rights to a safe meal Skyr and safe space to learn. These rights are afforded to them Custard through the Americans with Disabilities Act (ADA) and Dairy solids Section 504 of the Rehabilitation Act of 1973. Food allergies Galactose qualify as a disability under the ADA (since a potential Yogurt Ghee anaphylactic reaction can affect the ability to breathe), and as such, students can have a 504 Plan drafted. Half and half Hydrolysates This legal document includes all the accommodations that the school will provide for the child. Some examples of accommodations may include: • Offering a milk substitute for children. For children with • Designation of food-free or allergen-free classrooms. a 504 Plan due to an allergy, schools are required to offer • The right to dairy-free foods at meal or snack times. an alternative. Depending on the doctor’s directions, this • Specific seating arrangements in the cafeteria, like an may include a non-dairy milk substitute, juice, water, a allergen-free table. special formula, or another beverage. • Implementation of point-of-purchase alerts that help • For children with non-life-threatening food intolerances cafeteria staff double-check a young student’s tray or personal preferences, the school may optionally offer (without compromising student privacy). nutritionally-comparable milk alternatives. In order to • Offering parents easy ways to access recipes, such as an use these for a reimbursable meal, they must meet the online database, to check for allergens. current USDA standards for milk substitutes (which limits the options that can be served – i.e. no water, juice, or • Providing open and clear communication about the low-protein milk alternatives). process for modifying recipes or changing meal plans in the event of inventory issues. SUMMING IT UP Allergies can seem overwhelming, but with proper allergen- awareness procedures and a little culinary creativity, it’s easy to create meals that are both delicious and safe. E

12 NUTRITION & FOODSERVICE EDGE | May-June 2019 REFERENCES

• Agyemang A, Nowak-Wegrzyn A. Food Protein-Induced Enterocolitis Syndrome: a Comprehensive Review. Clin Rev Allergy Immunol. 2019 Feb 8. https://www.ncbi.nlm.nih.gov/pubmed/30734159 • CDC. Managing Food Allergies at Schools: The Role of School Nutrition Professionals. 2014. https://www.cdc.gov/healthyschools/ foodallergies/pdf/nutrition_508_tagged.pdf • Food Allergy Research & Education. Related Medical Conditions. https://www.foodallergy.org/life-with-food-allergies/food-allergy-101/ related-medical-conditions • FPIES Foundation. What is FPIES? 2017. http://fpiesfoundation.org/about-fpies-3/ • Jianqin S, Leiming X, Lu X, Yelland GW, Ni J, Clarke AJ. Effects of milk containing only A2 beta casein versus milk containing both A1 and A2 beta casein proteins on gastrointestinal physiology, symptoms of discomfort, and cognitive behavior of people with self-reported intolerance to traditional cows’ milk. Nutr J. 2016;15:35. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4818854/ • Food Allergy Research & Education. Food Allergy Training Guide for Hospital and Food Service Staff. 2006. https://www.foodallergy.org/ sites/default/files/migrated-files/file/hospital-food-training-faan.pdf • Venter C, Brown T, Shah N, Walsh J, Fox AT. Diagnosis and management of non-IgE-mediated cow’s in infancy - a UK primary care practical guide. Clin Transl Allergy. 2013;3(1):23. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3716921/

1 HOUR SAN CE Questions | FOOD PROTECTION CONNECTION CE CBDM Approved SAN

This Level III article assumes that the participant has thorough knowledge of the topic. CBDM The desired outcome is to integrate analysis and application of knowledge, incorporating continuing competence continuous quality improvement into best practice. where education advances performance

Reading When Milk Doesn’t Do a Body Good: Handling Dairy Allergies and Intolerances and successfully completing these questions online has been approved for 1 hour of Sanitation continuing education for CDM, CFPPs. CE credit is available ONLINE ONLY. To earn 1 SAN CE hour, access the online CE quiz in the ANFP Marketplace. Visit www.ANFPonline.org/ market, select “Publication,” then select “CE article” at left, then search the title “When Milk Doesn’t Do a Body Good: Handling Dairy Allergies and Intolerances,” purchase the article, and complete the CE quiz.

1. Which condition can cause severe, life-threatening symptoms 5. A resident in your long-term care facility reports that they are such as anaphylaxis? lactose intolerant. As a foodservice director, which would be the A. Milk allergy best next step to take? B. Sensitivity to A1 beta casein A. Eliminate all dairy from their diet C. Lactose intolerance B. Interview them to see which dairy products they may tolerate 2. Which condition causes severe repetitive vomiting C. Ignore it; it’s not a severe condition approximately one to four hours after consuming a trigger food? 6. Which of the following conditions qualifies as a disability in A. Sensitivity to A1 beta casein school settings, giving the child rights to certain foodservice accommodations? B. Non-IgE mediated cow’s milk protein allergy A. Milk allergy C. Food protein-induced enterocolitis syndrome (FPIES) B. Lactose intolerance 3. Which condition causes gastrointestinal discomfort due to C. Self-reported dairy intolerance undigested milk sugar entering the large intestine? A. Milk allergy 7. A child has lactose intolerance and her parents request a milk substitute be served at school. Under current USDA guidelines, B. Sensitivity to A1 beta casein which of the following is true regarding the school’s obligations? C. Lactose intolerance The school can... 4. A slice of cheese is accidentally placed on the sandwich of a A. Optionally serve water or juice for a reimbursable meal patient with a milk allergy. What is the appropriate action to B. Optionally serve nutritionally-comparable lactose-free milk take? for a reimbursable meal A. No action is necessary—it’s only one slice C. Be required to provide a milk alternative of the parent’s B. Remove the slice of cheese and serve the sandwich choosing C. Remake the sandwich with new ingredients

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