Food Standards Agency Symposium 2020 – a vision for the future of the food hypersensitive consumer

February 2020 – Notes on the presentations

Welcome – Heather Hancock, Chair FSA

Understanding the causes and diagnosis of allergies – Dr Paul Turner

Caring for a child with food allergies – Alexa Baracaia — Allergy influencer/advocate

Let's talk about Allergies – Carla Jones — Chief Executive, Allergy UK

The enforcement angle – Reporting and acting on incidents – Christina Heeley — Barnsley Metropolitan Borough Council

Keeping your customers safe – Rupi Zani — Pizza Express

How technology can help – Tarryn Gorre — Co-Founder, Kafoodle Caroline Monkhouse Flower — COO, Kafoodle

Getting the supply chain right – Darryl Thomson BSc. MIH. MRSPH. — Chairman, UK Hospitality Food Experts Group

Industry perspective on food allergens in an expanding vegan and free-from market – Dr Jayne Hipkiss — Chair, FDF’s Allergens Steering Group; Dr Stella Cochrane — Deputy Chair, FDF’s Allergens Steering Group

The FSA – our work moving forward – Michael Wight — Deputy Director of Policy, FSA

Welcome – an overview

Heather Hancock, Chair FSA

The aim of the Food Standards Agency's programmes are to improve the quality of life for the two million people who have to live with food allergies – and the nearly 5 million people who live with food intolerances. A job which is very much worth doing as research suggests that the quality of life of these groups is often worse than that of those who suffer from other intestinal conditions or from diabetes.

Focus on 16–24 year olds

But while the FSA in concerned for all food hypersensitivity sufferers their focus in the immediate future is on 16–24 years olds – a particularly vulnerable group.

Around 10 people per year die from food allergic reactions and the majority of those fall into this age group. Teenagers and early 20s naturally take more risks than other age groups and are especially reluctant to stand out from the crowd by declaring a food allergy – so are especially at risk.

The agency wants to work with this group and the food outlets serving them by:

• Influencing behaviour where possible. Research suggests that 'braver, bolder and more direct messaging' works better with this group – emphasising the consequences of getting it wrong.
• Normalising the conversation about food and allergy - encouraging allergy sufferers to speak out – share the consequences of interventions.
• Increasing traffic to the FSA's help site - ideally up to 30%
• Improving staff training

Research

The agency will continue to fund research – such as the TRACE study identifying the extrinsic factors which might influence an allergic reactions (whether you have just exercised or have been under stress).
Paul Turner (see below) will lead their team.

Regulation and oversight

• Consultation continues on the regulations covering Pre-packed food for Direct Sale (following the death of Natasha Ednan Laperouse after eating an unlabelled Pret a Manger baguette).
• The agency will continue to react to consumer demands and to work closely with industry investigating, especially, labelling inaccuracies and how these can be reduced.
• The agency also wish to make the reporting of allergic incidents easier and more efficient – coordinating with Trading Standards, Environmental Health and, in the case of a fatality, coroners.

Causes and diagnosis of allergies

Dr Paul Turner — Clinician Scientist / Honorary Consultant in Paediatric Allergy & Immunology, Imperial College London

Reactions to food are not new and although the public perception is that the incidence is increasing all the time, food allergy actually peaked in the 1990s and has plateaued ever since.

Reactions to food can be toxic (as a result of eating toxins) or non toxic.
Non toxic reactions can be immune reactions or non immune reactions.

• Immune reactions. These can be both short and long term are are potentially fatal or at least life threatening.
  A short term reaction could result in life threatening anaphylaxis.
  A long term reaction could result in damage to the body which could, in the long term, be life threatening– as in coeliac disease.
• Non-immune reactions. There are many other foods (such as an excess of sugar) which can disrupt the normal function of the digestion and therefore the body – often seriously – so are harmful to health but not life threatening.

However, different language is used by health professionals, researchers, regulators, the food industry and the public – which serves only to cause confusion.

Incidence

• Worldwide approximately 6% suffer from food allergy.
• 90% of their allergic reactions are to the top 14 allergens (cereals containing gluten; milk and milk products; eggs; peanuts; tree-nuts; lupin; soya; sesame; fish; crustaceans; molluscs; mustard; celery; sulphites)
• Hospital admissions for anaphylaxis between 1995 and 2015 rose by 8% in Australia and 5% in Britain.
• However, anaphylaxis is not binary– it can range from quite minor reactions to totally life threatening. The problem is the unpredictability of the reactions.
• The likelihood of dying from anaphylaxis remains less than 1 in 1,000 and it has been dropping over the last 20 years.
• The most frequent cause of anaphylaxis is not peanuts but milk – while 21% of children are allergic to milk but that drops to less than 8% in adults.

PAL/'may contain' labelling

As far as we know, no reactions are triggered by 'traces'. The perception that they are causes unnecessary anxiety amongst allergy sufferers.

PAL/May contain labelling should only be used when there is a genuine risk of cross contamination or of an allergen being mistakenly included in a product. If good manufacturing processes and protocols are followed and full risk assessments are done, there should be no need for precautionary allergen labelling.

Caring for a child with food allergies

Alexa Baracaia — Allergy influencer/advocate

Alexa described some of her experiences with her son Sydney, now 8 years old, who has multiple life threatening allergies.

Sydney had very bad eczema as a new baby but no connection was made with possible food allergy. At three months he had a life threatening reaction to egg but although treated in A&E, they were not offered an appointment for three months. They therefore saw a private allergist who found that Sydney had multiple potentially life threatening allergies including to egg, peanuts, sesame seeds – and banana!

Their life changed, Alexa started a blog about their experiences (yesnobananas...) and became a vocal advocate for the rights and needs of food allergic people. She now also runs a weekly allergy forum on Twitter– #allergyhour.

Of all of Sydney’s' allergens, Alexa finds sesame the most troublesome to manage as sesame seeds get everywhere.

Alexa then described the problems of eating out with allergies. Their experiences have not been good:

• Information is frequently inadequate and all to often incorrect.
• It can take an inordinate amount of time and effort to get the right information. It took 32 emails to arrange one family celebration meal that Sydney would be able to eat safely.
• Staff are often poorly trained if trained at all.
• Staff attitudes to those with allergies are frequently intolerant, lacking in understanding and on occasions both rude and unkind.

Unfortunately, while the recent publicity surrounding the deaths of Natasha Ednan Laperouse and Owen Carey has certainly raised the awareness of food allergy with the general public, it has seriously put 'the frighteners' on the food service industry. Far from engaging with their allergic customers to try and improve the situation, they are tending to retreat behind precautionary warnings that they cannot guarantee that any foods will be safe.

Welcome exceptions to this tendency that Alexa singled out were Nandos', Pizza Express and Leon who, after initially adding warnings to their menus, engaged with Alexa and have altered their procedures so that they are now happy to serve allergic customers.

Alexa's top messages going forward:

• The food service industry must take allergy seriously but – they must not be frightened off by the challenge of catering safely for allergy sufferers.
• Allergies are not a niche issue. Every allergy sufferer has friends and family who will eat where it is safe for the allergy sufferer to eat.
• Allergy sufferers are not asking for guarantees – they know that there is not such thing as guarantee-ably safe food. They are just asking outlets to take allergies seriously and to put in place training and procedures which will provide them with the information to make a responsible choice about eating in that establishment.
• Accurate information is vital. If the allergy sufferer is to make an informed and responsible choice, they must be given accurate information.
• Please think about how you and your staff talk to allergy sufferers. Allergy sufferers know that it will not always be possible to cater for them but they want to be talked to kindly – not dismissed as a nuisance or idiots.

Let's talk about Allergies

Carla Jones — Chief Executive, Allergy UK

There are 1,500 deaths in the UK from asthma each year but in how many of those is food allergy implicated?

Challenges of eating with food allergies, especially eating out:

• Lack of understanding in so many outlets of what is in the food.
• Failure to log ingredient changes.
• Failure to update on line information which frequently does not match what is actually on offer.

Quality of life

• Quality of life can be seriously impacted by food allergies:
• Stress and anxiety, leading to depression, over what one can/can't eat.
• When children are involved, stress over allowing others to care for the child.
• Excess vigilance
• Social exclusion for both adults and children – inevitable on not being able to take part in normal activities.
• Dangers of bullying - dating.

Training

• Formal training on food allergies should be included as part of the food hygiene rating.
• Some local training schemes are now incorporating allergy into hygiene training. However, it needs to be the first thing to learn as otherwise students tend to leave the class after the hygiene training has been covered, not staying for the allergy training.

The enforcement angle – Reporting and acting on incidents

Christina Heeley — Service Manager, Trading Standards, Barnsley Metropolitan Borough Council

Christina reviewed the case of Dylan Hall who died in 2015 as a result of eating a Chicken Korma which contained peanuts in an Indian restaurant .

• Dylan was allergic to all nuts but especially to peanuts but he had eaten Chicken Korma before and believed it to be safe. Because he was embarrassed to talk about his allergy in front of his girlfriend, he did not ask if the Korma had nuts – but even if he had, the restaurant had no information available regarding the contents of the Korma.
• Dylan was not carrying his Epipen, although it is possible that it would not have saved his life as the Korma not only contained almond powder but a significant amount of peanut powder.
• Although the restaurant was not prosecuted as Dylan had not informed them of his allergy, a number of good initiatives came out of this case.
• Barnsley Trading Standards officers were asked to investigate the case. While they were doing so they were approached by a consultant at the hospital to alert them to the fact that there had recently been similar case in the same restaurant of a 15 years old who had suffered an anaphylactic shock but who had survived.
• As a result, together with Dr James Griffiths, a clinician at Barnsley Hospital, Barnsley TS have developed a referral form to ensure that any allergy incidents that come to the attention of clinicians are automatically referred to the local authority to investigate.
• If this sort of cooperation could be rolled out countrywide it would create a much more joined up service for allergy sufferers. It would also hugely help in gathering much needed data on the incidence of allergic reactions in food service outlets and how they are dealt with.

E-ordering

Christina also pointed out that the potential for confusion with e-orders was considerable. Moreover, there was no way for an outlets servicing e-orders to know whether the exclusion of particular ingredient was because of preference or allergy.

She suggested that E-orders should include some sort of allergy alert.

Keeping your customers safe

Rupi Zani — Director of Safety and Wellbeing, Pizza Express

Having embarked some year's ago on offering allergen free foods to their customers, Pizza Express are fully committed to doing so as supportively and comprehensively as is possible.

Safety

• Conventional research suggests that what drives customers to a restaurant is the taste of the food.
• But observation of the gluten free customers who came to Pizza Express restaurants bringing their own gluten-free pizza bases suggested that they were less concerned about the taste of their pizzas and more concerned about being able to eat safely with their friends and families.
• So safety became the driving motivation behind Pizza Express' gluten free offer.
• But in a restaurant where loose flour was used to roll out pizza bases, those who reacted to gluten in flour could never be safe. So the first decision was made. Even though gluten free flour is five times more expensive than wheat-based flour, they would only use gluten-free flour in their restaurants thus making them safe for coeliacs.
• The development and manufacture of their own gluten-free pizza bases followed quickly. (Pizza Express regulars may be surprised to know that they now sell more pizzas in retail than they do in their restaurants!)

Awareness and engagement among staff and customers

Customers

• Staff are encouraged to pro-actively engage customers in a discussion about allergy by asking them if they have any. Table talkers are also being introduced encouraging customers to discuss their needs with staff.
• All complaints are dealt with personally and are followed up and investigated.

Staff

• There is an allergy forum in the business which includes every employee from the cleaners up to the board members.
• Staff are encouraged to report near misses – although they are understandably reluctant to do so. However, staff are never disciplined for genuine mistakes and they are encouraged to engage with 'a culture of safety'. Information about these misses is shared throughout the business, from the board down to the cleaners
• The forum looks at individual producers and processes seeking to identify potentially dangerous shortcuts that staff might try to make - and devise ways to improve the system.

Vegan trend

• It is hard to pinpoint what exactly is driving this trend – animal rights, health, environmental concerns or allergy – or a combination.
• Vegan regulations allow traces/may contain labelling for milk and egg. However, Pizza Express has decided to follow good allergy practice and will be making all their vegan foods genuinely milk and egg free.
• Indeed, as from spring 2020 all ingredients in Pizza Express foods will be treated as an allergen and all of their dishes will have full ingredient labelling.
• However, listing all ingredients on the label could create issues over possible cross contamination which would not be flagged on the label.

Moving forward

• Further standardisation of allergen signalling and documentation across the industry would be hugely helpful.
• The introduction of allergen safety thresholds for nuts/peanuts, milk and egg (like the 20 part per million for gluten) would be also be hugely helpful.

Information provision

Meanwhile, more information should be available in an easily accessible form. Bearing in mind the FSA's focus on 16-24 year olds as an especially vulnerable group:

• Could this information should be available via a smart phone
• Could the FSA develop an appropriate app?
• If so should it include a wider range of information than just allergy so as to make it more inclusive?
• Dangers. Will the information that goes into the app be reliable and will it be updated as needed?
  

How technology can help

Tarryn Gorre — Co-Founder, Kafoodle and Caroline Monkhouse Flower — COO, Kafoodle

Can technology help in communicating with consumers about food allergy?

Yes, it can, but there is a very low level of IT literacy (and a great deal of manual processing) among the small food operators who make up the majority of food outlets.

90% of small business just see food as food – but food is also data. Technology companies can develop processes to enable them to use that data.

How can technology help the industry?

• It can provide information not only on allergens but on suppliers, recipes, labelling, hygiene, costings etc etc for all eating occasions. Combining all information in one programme means that chefs will be forced to be aware of allergen issues when they log in for other daily information.
• It allows for full transparency and a clear audit trail.
• It can provide ongoing support and training for all businesses, large and small.

How can technology help the consumer?

• It can allow the consumer to find out about and order food on line.
• It enables good feedback from the consumer to the supplier.

Darryl Thomson BSc. MIH. MRSPH.

Chairman, UK Hospitality Food Experts Group

Although much in the food industry is confidential, food safety is the one area in which all players are prepare to share their knowledge and experiences.

However, it is difficult for small operators to find information about allergy and about suppliers.
Moreover, risk assessment protocols for large operations simply do not work for small businesses where space is at a premium and allergen free preparation has to share surfaces and implements with allergen filled preparation.

He suggested a reworking of the hierarchy of hazard control (ERICPD) to cover allergens:

ERIC

Eliminate – Remove unnecessary allergens (peanuts, sesame etc) from recipes and from the working kitchens

Replace – Wherever possible replace allergens such as milk or gluten with freefrom versions thereof. However, there could be both quality and cost issues in doing this.

Isolate – Separate allergens from other foods in storage and preparation areas. This is good practice where ever possible but may not always be possible in a small space.

Communicate – Inform customers about whatever risks you are unable to eliminate.

Darryl Thompson also suggested that static (printed) data is not helpful as it goes out of date so quickly. Fluid, real time data is what is needed.

Industry perspective on food allergens in an expanding vegan and free-from market

Dr Jayne Hipkiss — Global SRA Director Regulatory Compliance, Mars Wrigley Confectionery UK and Chair, FDF’s Allergens Steering Group; Dr Stella Cochrane — Science Leader, Allergy and Immunology, Unilever UK and Deputy Chair, FDF’s Allergens Steering Group

The vegan market is developing fast:

• Market estimated to be $12.7 billion in US this year
• Demand for vegan food grew by 987% between 2002 and 2017

However, points that need to be noted as far as the vegan market is concerned in relation to allergy:

• The industry's main consideration must be to keep the consumer safe.
• Law requires that food must be 'safe' e.g. not injurious to health – and that information must not mislead.
• All claims are voluntary but, if they are made, they must be substantiated and not mislead.
• PAL (Precautionary Allergen Labelling/May contain warnings) should be mandatory where justified.
• There is a great lack of regulatory consistency covering vegan foods.
• There is no legal definition of vegan food. The FSA define it as food which is 'not contaminated with non vegan foods'.
• The Vegan Society and the European Vegetarian Union both state that vegan food may not be suitable for allergics.
• European Vegetarian Union says that animal products (including dairy/milk) in a vegan product must not exceed 1% – but that would be a triggering dose for an allergic.
• Labelling needs to be harmonised but that harmonisation should be based around the needs of allergic consumers.

General points on labelling and reference doses/thresholds:

• Definitions are needed for both vegetarian and vegan
• Coordinated frameworks are needed for food labelling across the board.
• Reference doses (thresholds below which 99% of the allergic population will not react) are needed. However manufacturers should not rely on testing to these thresholds but on good manufacturing process with appropriate risk assessment and manufacturing protocols.

The FSA – our work moving forward – Michael Wight — Deputy Director of Policy, FSA

Michael Wight rounded up the day by outlining the FSA's objectives:

• To make the symposium held today an annual event
• To step up their allergy awareness campaigns both with industry and the consumer
• To commission research to establish the true extent of prevalence
• To offer training for consumers as well as industry – consumers need to ask the right questions if they want to get the right answers.
• To focus their efforts on the vulnerable group of 16-24 year olds.
• To get out Alexa's message that industry should be kind to consumers.

For more details see the FSA's site and the symposium website.

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