“The gluten-free cinnamon rolls are amazing!” Those emphatic words are emblazoned in my brain, stamped into my memory. As tears began to well in her eyes, Annalise, one of our counselors, looked around as if sharing a secret and said, “I haven’t eaten a cinnamon roll in five years! Could I please have your recipe?”
Annalise’s words touched our gluten-free cook almost as much as the experience of tasting delectable cinnamon rolls touched Annalise. For me, it was confirmation that a portion of Gilmont’s “Our Ministry” statement — “The kitchen staff is committed to serving delicious meals and sees accommodating special diet needs as part of our ministry” — had been met for Annalise.
Food Allergy Basics and Statistics
From our gluten-free week of camp to milk allergies to occasional Red Dye 40 and MSG intolerances, Camp Gilmont has seen an increase in food allergies and other special dietary needs. From a 2013 study by the Centers for Disease Control, food allergies now affect fifteen million Americans, with that number increasing roughly 50 percent between 1997 and 2011. Eight percent — or more than three million — children have a food allergy, the most common being peanut, milk, and shellfish (Food Allergy Research and Education, 2013).
To meet the ultimate goal of fulfilling the mission statement in our camp food service programs, particularly involving food allergies, food intolerances, and other special diets, we must first understand basic knowledge about food allergies and then learn a bit about food intolerances.
A food allergy occurs when a person with an extra-sensitive immune system has a reaction to a food protein that is typically harmless. Those proteins do not break down in the digestive system, which causes the immune system to react as if the protein is a harmful substance by sending white blood cells to attempt to defend against the supposed invader. This is what causes an allergic reaction. This reaction can present in a variety of symptoms, which vary depending upon the allergy.
Introducing the Big Eight
Although the Big Eight may sound like the name of the latest, greatest pop band of singing young men, they are anything but fan-worthy to those who have allergies to any, or many, of these foods. They are the eight most prevalent food allergens, and they are responsible for 85–90 percent of all Immunoglobulin E (IgE)–mediated foodrelated allergic reactions (IgE is an antibody produced by the immune system). The Big Eight allergens are milk; egg; peanut; tree nuts such as walnuts, pecans, cashews, etc.; fish; shellfish; wheat; and soy (Kim & Sicherer, 2011).
Milk allergy is an allergy to one or both of the proteins in milk, which are casein and lactalbumin (milk protein derived from whey). Most prominent in children three and under, it is estimated that 2.5 percent of children in this age group have a milk allergy. Up to 80 percent of these children will outgrow a milk allergy. For those who continue to have a milk allergy, it can display severe symptoms, including anaphylaxis, which can be life-threatening. Milk allergy is the third most likely allergy to cause anaphylaxis, behind peanuts and tree nuts (WebMD, 2012). Find a milk ingredients avoidance list at www.webmd.com/allergies/guide/milk-allergy.
It is important to note what milk allergy is NOT. Lactose intolerance, unlike milk allergy, does not involve the immune system, but instead involves gastrointestinal symptoms such as diarrhea, constipation, and bloating. Accommodating guests with lactose intolerance can be as simple as providing lactose-free milk products, but always consult with the camper or camper’s parents about specific substitutes before arrival.
Egg allergy is second in prevalence after milk. With egg allergy, egg white must be avoided as well as yolk to prevent cross-contamination. Eggs appear in a variety of foods, such as batters, mixes, puddings, salad dressings, and processed meats. As with any food allergy, egg can appear in other ingredients without “egg” in the name, so it’s important to always read food labels and be on the lookout for ingredients like lecithin, nougat, artificial flavoring, and natural flavoring. Egg allergy symptoms can range from mild, such as hives, to severe, causing anaphylaxis (Food Allergy Research and Education, 2013). Find a list of foods that commonly contain egg products at http://aafa.org/display.cfm?id=9&sub=20&cont=523.
Peanut allergy can be a lifelong allergy for 80 percent of children diagnosed. The most severe allergy, it can have life-threatening symptoms, including anaphylaxis. Up to 20 percent of those with peanut allergy experience anaphylaxis, which is a severe, multisystem reaction (Venter & Arshad, 2011; Keet, 2011). Symptoms range from hives to slurred speech; swelling of tongue, eyes, and face; difficulty swallowing and breathing; and unconsciousness. Up to 62 percent of fatal anaphylaxis occurs from peanut allergies (Keet and Wood, 2007). Find a list of foods that commonly contain peanut products at http://aafa.org/display.cfm?id=9&sub=20&cont=517.
Between 28 and 50 percent of tree nut allergies occur alongside peanut allergies. Like peanut allergies, 20 percent of tree nut allergy reactions are anaphylaxic (American College of Allergy, Asthma, and Immunology [ACAAI], 2010b).
A tree nut allergy avoidance list can be found at www.kidswithfoodallergies.org/resourcespre.php?id=60.
Of the approximately 0.4 percent of the population that have fish allergy, 30 percent are children. Symptoms range from mild to severe, including anaphylaxis. Fish allergy can be lifelong. Fish ingredients are often included in Worcestershire sauce, Caesar salad dressing, imitation crab, and Asian foods (ACAAI, 2010a). A fish allergy avoidance list is found at www.foodallergy.org/ allergens/fish-allergy.
Shellfish allergy symptoms can appear within minutes and can include hives; wheezing; trouble breathing; gastrointestinal symptoms; swelling of face, lips, tongue, or throat; and anaphylaxis. Those with shellfish allergy typically do not outgrow it. Sixty percent with the allergy are adults (Venter & Arshad, 2011). A list of foods to avoid is located at http://my.clevelandclinic.org/disorders/shellfish_allergies/hic_shellfish_allergies.aspx.
Wheat allergy is an IgE-mediated reaction to one of the proteins in wheat, which are albumin, globulin, gliadin, and glutenin (gluten). Wheat allergy is often confused with celiac disease, which is a digestive disorder. Most wheat allergies are triggered by albumin or gliadin. Symptoms are often immediate and can be caused by eating or inhaling wheat; they present as hives, eczema, asthma, and anaphylaxis (Asthma and Allergy Foundation of America, 2005). Foods to avoid for those with a wheat allergy are located at www.kidswithfoodallergies.org/resourcespre.php?id=52.
Soy allergy may be outgrown eventually, but it can also last into adulthood. Soy allergy symptoms are usually mild, such as hives or itching of the mouth, but they can rarely cause anaphylaxis (Kattan, Cocco, & Jarvinen, 2011). A soy avoidance list is located at www.kidswithfoodallergies.org/resourcespre.php?id=51.
The eight major food allergens are so predominant in America that the Food Allergen Labeling and Consumer Protection Act (FALCPA) was passed in 2004. FALCPA requires U.S. food manufacturers and packagers to list the eight major allergens on all packaging and include the specific type of allergy, such as salmon (fish) or almonds (tree nuts). Further, the law states that the print must minimally be the same size as all other ingredients. Food items to which FALCPA does not apply include meat, poultry, eggs, fruits, and vegetables (Kim & Sicherer, 2011).
Australia, Europe, Canada, and New Zealand also have labeling laws for food allergens; however, food allergens required to be listed differ. The European Union outlines twelve food items as allergens, including sulfites — which Australia, Canada, and New Zealand also consider to be an allergy — whereas the U.S. defines them as a food intolerance. This difference brings us to non-allergens classified as food intolerances in the U.S. (Kim & Sicherer, 2011).
Food intolerance is defined as a nonallergic, adverse digestive system response caused by foods (Medical News Today, 2013). Like food allergy, food intolerance can cause stomach pain, nausea, vomiting, and diarrhea. Symptomatically, food intolerance is different in that it can also present with gas, cramps, bloating, heartburn, headaches, and irritability. The most common food intolerances are:
- Lactose (discussed earlier)
- Tyramine — amino acid based and used to smoke, pickle, or preserve
- MSG — a flavor enhancer added to soups, Chinese food, canned foods, processed meats, etc.
- Non-celiac gluten sensitivity — similar symptoms to celiac disease, but without the intestinal damage
- Artificial sweeteners and colors
Although the FDA Food Advisory Committee released a statement in 2011 saying there are possible, minimal, behavior-related reactions to artificial colorings in some children, with or without ADHD (Weiss, 2012), studies at Purdue University (Stevens, LJ, et al., 2011) and University of Australia Melbourne (Rowe & Rowe, 1994), have proven that intolerances to artificial food colors can greatly exacerbate issues such as restlessness, irritability, and sleeplessness in children with behavioral disorders from ADHD. Strickland’s Eating for Autism concludes that artificial colors, flavors, sweeteners, and preservatives, especially BHT, effect autistic children adversely through behavior, based on research (2009).
Our Role in Food Allergy Accommodation
A recent American Camp Association (ACA, 2013) public policy article discussed judgment brought by the U.S. Department of Just ice against Lesley University (Massachusetts) regarding accommodations to dining hall plans for students with food allergies under the Americans with Disabilities Act (ADA). Some residential students, after purchasing the required meal plan, were unable to eat some foods offered on the plan without food allergy symptoms. While this judgment was made for a university and not for the camp setting, the related guidance document released by the Department of Justice (DOJ) details new requirements for the Lesley University food service, which can serve as a tool for food allergy accommodation in camp food service.
The DOJ stated that per the ADA, all public food service venues are not required to serve allergen-free foods, but suggest at a minimum for restaurants/food services to answer questions about food ingredients and to substitute or omit allergens where possible.
Training Food Staff
Food service staff should have annual training but can have ongoing education and training to accommodate special dietary needs in various ways. I was fortunate to employ a summer intern, Julia Nelson, who has a BS in nutrition, is a registered dietician, and has previous special diets administration experience. While on staff, not only did her expertise fine-tune our food allergy process, but Julia transformed my food allergy notes and copies of allergen lists into a booklet for staff training titled “Food Service Special Diets and Allergies Book.” This is now used for annual staff training and is available to staff at any time for reference.
Food Allergy Safety Zone
In Serving People with Food Allergies, Joel J. Schaefer (2011) makes some of the following suggestions in order to safely serve allergen-free menu items. Determine a “Food Allergy Safety Zone” where only foods without the Big Eight allergens are prepared. This can be a designated work table or other kitchen area with the following basic items to be used ONLY for prep in this area:
- Skillets, pots, sauté pans
- Baking sheets with covers
- Small griddles/grills for meats/pancakes
- Waffle iron for gluten-free waffles
- Small fryer
- Individual steamer
- Counter top oven
- Undercounter refrigerator for allergenfree perishables
- Designated utensils for allergen-free cooking/serving only
- Cutting boards
- Shelves above prep area for bowls, plates, etc., designated for allergen-free foods only
- An undercounter dishwasher, or builtin sink at one end of work table
- Nonlatex gloves
- Food allergy recipe book with recipes designed/converted for large groups
The following tips are important for decreasing cross-contamination:
- It is imperative that one cook is responsible for that work station, and that this person does not prepare foods there that contain allergens — or work in areas of the kitchen that contain allergens — while on allergen-free cooking duties.
- Never wash allergen-free cookware, utensils, and accessories with traditional items.
- Wash hands or change gloves after coming in contact with door handles of any type.
- A small holding area for prepared foods is beneficial, such as a portable food cart unit with a door, to ensure food safety. Another option is to keep a countertop, multishelf warmer with a door in the Food Allergy Safety Zone, where individually labeled plates with covers can be kept until serving time.
- Label all allergen-free meals / menu items with specifics such as “gluten free,” or “soy free.”
- In the camp setting, it is advantageous to label the cover of the specially prepared item with the name of the camper/staff member.
- Thoroughly READ ingredient labels!
- When in doubt, leave it out! (Schaefer, 2011)
Serving Food-Allergic Campers
A difficult step in the allergy-free process for our camp has been identifying the camper/guest with food allergies. Obstacles to identifying the individuals with food allergy/allergies vary. Sometimes, registration forms are not completed properly — and after ordering food, we discover that there are three campers with food allergies arriving for our next camp session. Finding/ making quick food allergy identifications can be a challenge for food service staff. The Asthma and Allergy Foundation of America suggests using a QuickAllergy Card, which outlines food allergens, or colored bracelets for campers with the allergens written on the front. Either is shown to serving staff upon approaching the line.
In one study, teens were less likely to heed advisory labeling and more willing to take risk with al lergens (Mudd & Wood, 2011). I have discovered that some teens find it embarrassing to be singled out, even by discreetly offering a prefilled plate in a noisy cafeteria. Understandably, some may not want others to know they are different. A teen once came through our serving line and rejected MSG-free marinara, exclaiming, “No, thanks . . . I told my grandmother NOT to mention my food allergies!”
So, how do we balance the assurance of food safety for those with allergens, our follow-through responsibility with parents, our legal obligation to protect health information, and our mission to honor the individual dignity of campers? We can distribute accountability to three parties — camp, parents, and camper (Church Mutual, 2013). Some suggestions for a three-way agreement:
Policy/contract for parents should contain:
- Describe camper’s ability to manage special diet
- If camper can self-manage diet, require a note from healthcare provider
- Ask parents to provide a written plan for camper in case of reaction (many health forms contain area for listing symptoms; this is a step further)
- Have parents sign a release statement with signature field stating that food allergies can be shared with staff on need-to-know basis, per HIPAA law
- Agreement to be signed by camper, stating he/she will:
- Ask questions about unfamiliar foods
- Not trade food
- Not eat anything parent hasn’t approved (Mudd & Wood, 2011)
- Agree to present food allergy identification card/bracelet to food service staff so that prepared allergen-free foods are offered
- Eat allergen-free foods the camp has prepared post consultation with parents
- Camp responsibilities:
- State to what extent camp can/ cannot feasibly accommodate special dietary needs in your camp policies
- Share that food service staff have been properly trained
- Inform that all allergen-free meals are prepared in a designated place with designated allergen-free materials
Our foremost goal in camp food service should always be camper safety. With solid policies and planning, communication with parents, smart food staff training, and lots of label-reading, your efforts will exceed this goal and earn respect and confidence from parents and campers.
Camp Gilmont’s Gluten-Free Cinnamon Rolls
Yield: 8–10 rolls
NOTE: 4 cups superfine brown rice flour, 1¹/³ cups potato starch (not flour), ²/³ cup tapioca starch. Combine ingredients in large ziptop bag. Shake until well blended.
Place sugar, butter, and vanilla in a medium bowl. Then stir in enough milk to reach a very thick consistency. Spread over warm rolls as soon as they are placed on a plate to let the
ACA. (2013). Food allergies may constitute a disability under the Americans with Disabilities Act. Retrieved from www.ACAcamps.org/publicpolicy/ADA-food-allergies
ACAAI. (2010a). Fish allergy. Retrieved from www.acaai.org/allergist/allergies/Types/foodallergies/types/Pages/fish-allergy.aspx
ACAAI. (2010b). Tree nut allergy. Retrieved from www.acaai.org/allergist/allergies/Types/foodallergies/types/Pages/tree-nut-allergy.aspx
Asthma and Allergy Foundation of America. (2005). Wheat allergy. Retrieved from www.aafa.org/display.cfm?id=9&sub=20&cont=519
Church Mutual Insurance. (2013, Winter). Coping with food allergies in the camp environment. Risk Reporter for Camps and Conference Centers.
Kattan, J., MD; Cocco, R., MD; & Jarvinen, K., MD. (2011) Milk and soy allergy. In Sharma, H., Wood, R., & Coppes, M (Eds.), Pediatric clinics: Food allergy in children. (pp. 407-418). Philadelphia, Pennsylvania: WB Saunders Company.
Keet, C., MD. (2011). Recognition and management of food-induced anaphylaxis. In Sharma, H., Wood, R., & Coppes, M (Eds.), Pediatric clinics: Food allergy in children. (pp. 377-378). Philadelphia, Pennsylvania: WB Saunders Company.
Keet, C., MD; & Wood, R., MD. (2007). Food allergy and anaphylaxis. Immunology Allergy Clinic of North America, 27, 193-212.
Kim, J., MD; & Sicherer, S., MD. (2011). Living with food allergy: Allergen avoidance. In Sharma, H., Wood, R., & Coppes, M (Eds.), Pediatric clinics: Food allergy in children. (pp. 459-460). Philadelphia, Pennsylvania: WB Saunders Company.
Medical News Today. (2013). What is food intolerance? What causes food intolerance? Retrieved from www.medicalnewstoday.com/articles/263965.php
Mudd, K., RN; & Wood, R., MD. (2011). Managing food allergies in schools and camps. In Sharma, H., Wood, R., & Coppes, M (Eds.), Pediatric clinics: Food allergy in children. (pp. 471-480). Philadelphia, Pennsylvania: WB Saunders Company.
Rowe, K.S., & Rowe K.J. (1994). Synthetic food coloring and behavior. The Journal of Pediatrics, 125. Retrieved from www.ncbi.nlm.nih.gov/pubmed/7965420
Schaefer, J. (2011). Serving people with food allergies: Kitchen management and menu creation. Boca Raton, Florida: CRC Press, Taylor & Francis Group.
Stevens, L.J.; Kuczek, T.; Burgess, J.R.; Hurt, E.; & Arnold, L.E. (2011). Dietary sensitivities and ADHD symptoms: Thirty-five years of research. Clinical Pediatrics, 50(4). Retrieved from www.ncbi.nlm.nih.gov/pubmed/21127082
Strickland, E. (2009). Eating for autism. Cambridge, Massachusetts: De Capo Press.
Venter, C., PhD, RD; & Arshad, S.H., DM. (2011). Epidemiology of food allergy. In Sharma, H., Wood, R., & Coppes, M (Eds.), Pediatric clinics: Food allergy in children. (pp. 327-345). Philadelphia, Pennsylvania: WB Saunders Company.
Weiss, B. (2012). Environ Health Perspective, 120(1). Retrieved from www.ncbi.nlm.nih.gov/pmc/articles/PMC3261946/
Kimberly Whiteside Truitt, CFM, is the food service director/accreditation coordinator at Camp Gilmont in Texas. A graduate of Williams Baptist College, Kimberly is married to Thomas and mom to Harrison and Benjamin.
Originally published in the March/April 2014 Camping Magazine.