Nut is a confusing word because it refers to several things that are only distantly related. Peanuts grow on a little vine in the ground; those are a type of legume--closely related to peas and lentils. Almonds are a type of tree nut; tree nuts belong to several botanical families. Almonds are what McDonald's are planning to add to its Canadian salads. More about almonds later.
Now let's introduce a different element to this conversation--another allergy that isn't nuts. I know what it means to stop eating restaurant salads because my own allergies have forced me to stop eating salads too, not just at McDonald's but at all restaurants. No food allergy charity has been advocating on behalf of people who have my allergy even though it would be simple assist us. I am not allergic to any vegetable either; the problem is cross-contamination. A simple protocol that takes just one to two minutes using equipment already in any kitchen could make salads safe to eat again, but no one is training restaurant staff in this procedure.
I am not asking McDonald's or any other chain to take my allergens off its menu. Let's make this clear; this request is much more modest.
It would be useful to be able to contact Food Allergy Canada or FARE or FAACT and get a handout in their letterhead that I could hand to restaurant staff--or at the very least a guidance page on an official website for food service workers that spells out how to accommodate my needs. Any of the major charities could publish this. None does.
The procedure is straightforward: wash trace residues of fruit off the cutting surface and the implements that handle my food. Use soap and water. This isn't difficult but it is absolutely essential.
Can fruit allergies really be as severe as nut allergies? Yes they can. Don't take my word for it; here are two examples from the medical literature of patients who suffered anaphylactic shock because food service workers used contaminated implements. These cases happened seven years apart. Both patients were having dessert and, because they were responsible and careful about managing their condition, neither ordered a dish that contained their allergen--yet the implements used to handle their food contained trace allergen residue after serving other customers.
Read the results for yourself:
In May 2010, after an accidental ingestion of kiwi hidden in vanilla ice cream (it is most likely that a small amount of kiwi fruit was on a spoon used for scooping ice cream) the patient developed shortness of breath, swelling and numbness of tongue, hot flashes, dizziness and temporary loss of consciousness, involuntary urination and defecation... A small amount of the allergen left on an ice cream scooping spoon can result in a full-blown life-threatening anaphylactic shock.A different case from 2003:
We present the case of a 29-year-old white woman who had several episodes of severe anaphylaxis after consumption of kiwi fruit, including 3 episodes of allergic shock with loss of consciousness and subsequent hospitalization. For the first 2 episodes, the symptoms started shortly after ingestion of pure fresh kiwi preparations without concomitant consumption of additional foods, pointing to the causative role of kiwi. Most remarkably, in a third episode anaphylaxis had been elicited by minute amounts of kiwi left on a knife that was subsequently used to prepare a strawberry dessert served to the patient in a restaurant.Both of these patients lost consciousness and one of them stopped breathing.
Subsequent medical testing confirmed the severity of their allergy and the cause; these cases appeared in peer reviewed scientific journals.
This is not a blame game. The food service workers are not in the wrong; it would not be fair to point fingers over not following a safety procedure they had never been taught. Those two patients are not at fault either--no organization has developed cross-contamination guidelines for anaphylactic fruit allergy patients. You have to be adept at searching the medical literature to locate these cases because the food allergy charities overlook anaphylaxis to fruit.
The "nothing found" search result in the image at the top of this post demonstrates how neglected this segment of the community is. Severe reactions to the foods in those medical journal case studies are usually diagnosed as anaphylactic cases of Oral Allergy Syndrome. A keyword search for "oral allergy syndrome anaphylaxis" turned up nothing at the Food Allergy Canada website.
Let's refine the search terms. Both of those two instances were reactions to kiwi, which is the best documented of the OAS anaphylaxis allergens. Kiwi is the allergen that caused both of those near fatal examples. Yet search for "kiwi anaphylaxis," no results again:
The best that further searches could scrounge from the Food Allergy Canada site was an incidental result for a "fruit anaphylaxis" search that turned up an unrelated page about sulfites.
The official Canadian government website for the Canadian Food Inspection Agency is only slightly more useful; it acknowledges that Oral Allergy Syndrome anaphylaxis exists. Compare that brief mention against the same agency's vigilance with nut allergies. To be fair to the public servants, nut allergies receive enhanced protection under Canadian food safety regulation; OAS does not.
Among general audience websites the absolute best summary I have managed to find is hosted by the American College of Allergy, Asthma, and Immunology, which devotes a full paragraph to anaphylactic cases at the end of its OAS page. That paragraph outlines symptoms to notify an allergist about a potentially worsening case, it cites statistics on the percentage of OAS cases that develop into anaphylaxis, and it cautions about carrying an epinephrine auto-injector.
Yet even at the best site of its type, not one word about cross contamination risks or preventive protocols.
Before this goes any further, a few words of reassurance: Oral Allergy Syndrome is a mild condition for most people. Only one to two percent of OAS cases progress to anaphylaxis. So nearly everyone who develops OAS experiences nothing worse than a little itching and swelling. So unless you happen to be in that small percentage of cases that go anaphylactic, you will not have the same set of risks and worries as a person who has peanut allergies.
The problem is that if you do fall into that small percentage whose OAS is as severe as nut allergies, no one tells you very much and nobody advocates for you.
I do not happen to be allergic to kiwis; I am allergic to apples. I am also anaphylactic to almost the entire Rosaceae botanical family. Birch pollen-Rosaceae cross-reactivity is one of the best known OAS manifestations. In biomedical jargon, OAS is an IgE-mediated allergy. That means any OAS allergen can cause anaphylaxis. So because my allergy is anaphylactic I run basically the same risk from contaminated serving implements that the patients in those case studies were running: that could happen to me--and although some individual cases are too severe for this precaution, a simple soap and water washing can make a knife safe to use on my food. This isn't just about myself, of course--there are thousands of other people with the same immune system malfunction.
It would not be too difficult to design flexible safety protocols for the less common allergens because for most of us those protocols are only slight variations on the protocols already used to prevent seafood or wheat contamination for those more allergies.
Yet the normative response to people like myself is to say "Carry an Epi-Pen," then shrug and walk away. That is not good enough; it makes no sense to manage a medical condition this dangerous on a crisis response basis. Avoiding foods that contain our allergens is only a first step. We are left to fend for ourselves in terms of discovering what cross-contamination is and how to prevent it through trial and error. This needs to change.
I eat salads at home. After all, I am not allergic to any vegetable. I stopped eating all restaurant salads after a severe reaction. The only safe assumption is that every professional kitchen is contaminated because nobody is teaching anyone how to prevent this risk.
People who have the more common types of food anaphylaxis often carry restaurant cards to alert staff how to accommodate them. That approach does not help people like myself because no one in the kitchen has been trained in what to do when they see my allergen list. The instructions have not been written.
This situation persists even though food anaphylaxis is covered under the Americans with Disabilities act in the United States and under disability protection laws in Canada.
Remember how I mentioned earlier that tree nuts belong to various botanical families? Here's the kicker: almonds are in the Rosaceae family. No other tree nut is in the Rosaceae family, which is mostly fruits and berries. As the ACAAI website linked above mentions, almonds are also a recognized OAS allergen. By pure chance I am not allergic to almonds. Every case of OAS has quirks of its own and almonds, along with strawberries, are the only two foods in the Rosaceae family I am able to eat.
So imagine sitting here watching this advocacy campaign to make McDonald's salads safe for allergy sufferers--the first time I've ever seen a campaign that touched on OAS anaphylaxis in any way. Except they aren't doing it because of the OAS; they're doing it because almonds are a tree nut. People who get either type of allergy can have an immune response to almonds.
Nearly ten percent of the food anaphylaxis community has a life threatening immune reaction to something that is not a common allergen. We constitute a significant portion of the community, yet we get overlooked.
I have had to avoid all restaurant salads since 1994. That's a long time to wait in silence while the charities advocate for other patients.
