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hen Mr. Smith was admitted to a long-term care facility, his son told the certified dietary manager: “He’s allergic to milk. But he loves cheese and ice cream, so be sure to let him have them.” How many times has this type of patient been admitted to your facility? Should Mr. Smith avoid all milk and milk products, including ice cream, cheese, and foods made with milk? Maybe, maybe not.
       Often, patients who report a food allergy actually have intolerance, as is probably the case with Mr. Smith. It is estimated that only 2% of adults have true food allergies. In one survey, however, up to 20% of adults reported being allergic to at least one food.¹ The distinction between allergy and intolerance is important because allergies can cause life-threatening reactions while intolerances generally cause only temporary discomfort. Misdiagnosed or misreported food allergies can result in an unnecessarily restricted diet and even nutrient deficiencies.

Food Allergy

       A true food allergy is an abnormal reaction to food that involves the immune system. When an offending food is eaten, the body, in response, produces the antibody immunoglobin E (IgE). During an allergic reaction, the body releases chemicals, including histamine, to protect itself. Symptoms of food allergy usually occur within a few minutes or up to two hours after eating. An allergic reaction might be mild and result in hives or eczema, nausea or vomiting, or diarrhea. In some cases, the reaction is more serious and results in asthma-type symptoms, difficulty breathing, coughing, or wheezing. In severe cases of food allergy, the result is anaphylaxis, a reaction that involves the whole body and can cause a loss of consciousness, shock, or even death. The signs of anaphylaxis may be a feeling of warmth, a flushing or tingling in the mouth, or a red and itchy rash. Other symptoms might include feelings of light-headedness, shortness of breath, severe sneezing, vomiting or diarrhea, or anxiety. Symptoms of anaphylaxis are reversed by treatment with an injectable epinephrine or antihistamines. Other emergency measures may be needed. It is crucial for anyone with possible anaphylaxis receive emergency treatment immediately.

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       Food allergies appear more often in someone who has a family history of allergies, but they can be outgrown. The most common foods that cause allergic reactions are peanuts, tree nuts, milk, eggs, fish, shellfish, wheat, and soy. To confirm a true food allergy, an allergist should be consulted. Allergy testing may involve a blood test (called a RAST test) or a skin test for which a potential allergen is injected into the skin and a reaction is noted. Food allergies can also be diagnosed in part by a “food challenge.” This is where a food is introduced and a patient monitored for an allergic reaction. This testing should be medically supervised.
       In long-term care facilities, food allergies can be difficult to pin down. A food reaction years (or even decades) ago might be reported as an allergy even if it is food intolerance. A true food allergy may have been present at one time but since outgrown. In residents with poor cognition or memory loss, vague comments about food allergies often cannot be substantiated. The inability to confirm food allergies in this population means that every report of food allergy should be taken seriously.

Food Intolerance

       Food intolerance is an abnormal response to a food that does not involve the immune system. Intolerances are more common than food allergies. Symptoms may be similar to those of a food allergy, such as gastrointestinal (GI) problems, hives, or itching around the mouth. Intolerance symptoms are usually mild and may be inconvenient, but they are not usually life-threatening.
       A good example of food intolerance is lactose intolerance, a condition that results in nausea, cramping, bloating, gas, and diarrhea with consumption of dairy foods. The symptoms result from intolerance to lactose, a carbohydrate found in milk. Most lactose-intolerant persons can drink milk and eat dairy foods in small amounts without having a reaction. Persons can have intolerances to many different types of foods, not just dairy foods. Other common intolerances include fruits and vegetables and spicy or greasy foods. Patients often report, “I like [type of food], but it doesn’t like me.” In most cases, this is food intolerance rather than a true allergy.
       When a person has food intolerance, he or she usually able to identify how much of the food he or she can eat without experiencing negative effects. To assure a varied and nutritious diet, residents with intolerances should be encouraged to eat as much of the offending food as they can tolerate.

Treatment for Food Allergies and Intolerances

       The only treatment for food intolerances is to avoid the food or treat the symptoms. In the case of food allergies, severe reactions can be treated with epinephrine or antihistamines as mentioned above.
       Those who have experienced an anaphylactic response must strictly avoid the offending food, even in small amounts and in mixed food products. In the case of wheat, soy, and dairy, these foods are found as ingredients in many food items, creating a need for careful attention to product labeling and sometimes resulting in a very restricted diet. This can be a challenge for kitchen staff in long-term care facilities as well as patients who are confused and do not understand their diet restrictions.

Implications for Caregivers

       Obtaining confirmation of food allergies creates challenges when a patient has a cognitive impairment. Staff in long-term care facilities should attempt to verify food allergies from medical records and reports from the patient and his or her family. If a patient has experienced anaphylaxis in the past, the patient/family will usually report it upon admission, and medical records can confirm it. Staff should attempt to determine if reported food allergies resulted in anaphylaxis or only minor symptoms and document accordingly in the admission assessment.
       Finding the balance between completely eliminating foods and providing a nutritious and varied diet can be a challenge in the case of reported food allergies. It is critical for a healthcare facility to provide a safe environment for all residents. For patients with allergies, safety could depend on the differentiation between a food allergy and intolerance. Because of the potentially severe nature of an anaphylactic reaction, complete avoidance of an offending food is the best policy for any healthcare facility, even if the allergy is reported as mild. Unless the patient or family specifies otherwise, all foods containing the offending food should be avoided, even if they are present in very small quantities in a mixed dish or processed food.
       If a food allergy is reported and cannot be substantiated, the diet order should read “No [type of food] due to possible food allergy.” That food should be listed on the patient’s tray card as a food to avoid. Dietary staff should document on the nutrition assessment and/or progress notes that the resident has a suspected food allergy.
       A resident sometimes reports a food allergy but later requests that food. As with any doctor’s order or medical procedure, it is the resident’s right to refuse care. In that case, the facility should have the resident sign a waiver stating he or she knows he or she is violating doctor’s orders. If the resident is not cognitive, the responsible party, legal guardian, or healthcare power of attorney should sign the waiver on his or her behalf. In some cases, a waiver for a food allergy may provide a more varied diet and improve a resident’s satisfaction with his or her food and quality of life. If an allergic food is provided as requested by a resident or eaten without the consent of the facility, staff should closely monitor him or her for an allergic reaction and intervene if necessary.
       In the case of food intolerance, dietary staff should attempt to determine how much of the food the resident wants or can tolerate by talking with him or her and/or family. Complete avoidance of a food simply because of a food intolerance may not be necessary or in the best interest of the patient. This is especially true if the food is one the patient really enjoys that can help improve the quality of his or her diet.
       Does Mr. Smith’s son have a food allergy to milk? Probably not. He most likely is lactose-intolerant and can tolerate some dairy foods. His family’s request for cheese and ice cream should be honored by the facility. Providing the food he enjoys and can tolerate may make him a happier, healthier patient.