Increasing allergens declarations through proactive communication

Roughly 5% of the UK population report having a food hypersensitivity, which includes both food intolerances and allergic reactions, and 60% of those (3% of the UK population) have IgE-mediated food allergy. Such allergies, caused by an allergen-specific immunoglobulin E (IgE) antibody, can lead to rapid and potentially life-threatening allergic reactions. Hospital admissions for food anaphylaxis are increasing: from 1998 to 2018 they increased from 1.23 to 4.04 per 100,000 population per year, an annual increase of 5.7%. The fastest increase is in children under 15 years, whose hospital admissions during that period increased from 2.1 to 9.2 admissions per 100 000 population, an annual increase of 6.6%. An analysis of deaths due to foodborne allergens between 1992 and 2012 found that the majority of incidences (59%) occurred as a result of food being bought from food businesses, with about a quarter of those originating from take-aways. A particular hazard of eating out of home is that, even if consumers are aware of their own food allergies, they may not know all the ingredients of their purchases. In 2021, after the death of a minor who had an allergic reaction to a baguette that did not require allergen labelling, the UK Government introduced ‘Natasha’s Law’, which requires any business producing pre-packaged for direct sale food to label it with a full ingredients list, with allergenic ingredients emphasised within the list. This supplements previous legislation from 2014, which required Food Business Operators (FBOs)—restaurants, cafes, takeaways, and businesses that produce, manufacture or pre-pack food—to inform customers if their food and drink products contain any of 14 key allergens, either explicitly in writing or with a clear instruction about how to obtain the information (e.g. asking staff). FBOs selling non-pre-packaged food are not obliged to provide full written information. A report into provision of food allergen information, prepared in the lead up to the 2014 legislation, found that 20% of businesses selling non-pre-packaged food only provided allergens information orally and 7% provided no information at all, and that training of staff was variable. There was a consensus amongst businesses that training was needed for staff about how to impart allergen information to customers and clients. That study also reported that the most common reason for not giving information about all the 14 food allergens was ‘no customer demand’. Similarly, a study involving staff from 28 takeaway businesses found unanimous agreement that it is the customers’ responsibility to inform them of food allergies. However, consumers with allergies may be dissuaded from actively seeking information about allergens. Many of them feel that asking questions about the food may lead to them being perceived as fussy, and therefore risks them being embarrassed, and that asking might increase the risk of misinformation and mistakes. A survey of adults with food hypersensitivities found that 12% (of the 885 respondents) said they would never ask staff in a restaurant or take away for allergens information before ordering and 14% would ask only about half the time or occasionally. The respondents were asked how comfortable they felt about asking and 39% were not comfortable (did not respond either ‘very’ or ‘fairly’ comfortable); 36% were not confident (did not respond that they were ‘very’ or ‘fairly’ confident) that the information provided verbally by staff when eating out allows them to identify foods that cause a reaction. (Confidence may be lower in younger age groups: a separate survey of those aged 16-24 found 54% did not respond they were ‘very’ or ‘quite’ confident when asking for allergen information.) Further, how comfortable participants were in asking for information from staff when eating out, and how confident they were in the verbal information provided when eating out, were negatively correlated with impairment to quality of life (impairment measured from 1 ‘least’ to 7 ‘most’, r = -.30 for comfort and r = -.36 for confidence, all correlations p < 0.01); feeling more comfortable in asking staff for information about food when eating out predicted better quality of life in a regression analysis (standardised beta = 0.21). These barriers could be overcome if staff were more proactive in communicating allergens information. When asked which actions would help them manage their condition, 72% of 16-24 year olds said that it would help if waiting staff could pro-actively ask if anyone on the table has a food allergy or intolerance when taking the reservation or the food order. Further, if staff take the lead, that could be good for businesses if it increases the amount of business they get from people with hypersensitivities. The majority of respondents in a survey of 16-24 year olds with food hypersensitivity reported having avoided eating out in the last six months due to their hypersensitivity (63% of those with a food allergy and 51% of those with a food intolerance). Further, customers with food allergies and intolerances say that the best eating out experiences involve knowledgeable and attentive staff. This is not surprising, since knowledgeable staff should indicate a safer experience. Therefore, the FSA commissioned a feasibility study, designed and run by Kantar’s Behavioural Practice, from 3rd-20th March 2020. Staff in branches of a multinational FBO were trained to ask customers “Do you suffer from any food allergies or intolerances?” at point of sale and to follow up with relevant information on allergens for customers who answered “Yes”. This was a matched pairs cluster quasi-randomised experiment, with five pairs of branches at one large FBO selected for participation. After service, customers in all ten branches (5 intervention, 5 control) were asked to complete an in-store survey on a tablet. They were asked about their perception of the safety of the food sold in the FBO, their trust in the FBO, their confidence to ask about allergens on future visits, their satisfaction with the visit, and their allergen status. The trial was scheduled to run for two months, but had to be curtailed due to the pandemic (UK government directives resulted in the temporary closure of the FBO). The aim of the feasibility study was to investigate the practicability of a fully powered trial. Specifically: (1) the willingness of FBOs to participate, (2) the willingness of customers to participate, (3) consistency of staff delivery of the intervention, (4) suitability of the survey as a method of measuring outcomes, and (5) appropriateness of the analytical approach. Results suggested that a full trial would be feasible, with the main difficulty being FBO recruitment, which was adversely affected by the pandemic. The survey response rate was about 0.3%, which was sufficient to run the analysis (and informed design and power calculation considerations for this trial), but was lower than expected—possibly due to people not wanting to handle the tablets during the pandemic. The intervention was relatively consistently delivered in the treatment group, with between 65.4% and 100% of customers who completed the survey saying they had been asked. However, many customers in the control arm were asked about allergens (30.8%-65.6% across the five branches). This suggests the need for increased fidelity checks on both control and intervention groups, and the desirability of a sensitivity analysis. The survey measures were sensitive enough to run a multi-level analysis and to get an estimate of the intra-class correlation coefficient to inform the power analysis for this trial. The feasibility study was not powered to investigate performance on outcome measures; however, the numerical effects of being asked about allergens at point of sale were in the direction that was expected. Safety concerns about the food was numerically lower amongst those who were asked about allergens (M = 2.31 vs M = 2.49), trust numerically higher (M = 4.38 vs M = 4.36) and confidence about asking staff for information about ingredients numerically higher (M = 4.68 vs M = 4.57). (All measured on 5-point Likert scales.) It was not possible to collect information on allergens declarations, which we had expected to get from till data, because of data sharing issues. At the same time as the feasibility trial was taking place, the FSA commissioned a UK-wide public consultation, which involved a range of stakeholders (food businesses, patient groups, health care and academia, local authorities and the FSA) to identify unanswered research questions. That consultation concluded that “improving traceability of allergens in the food supply chain” was one of five priority themes. Under that theme, the priority research questions were: How should information be communicated (through the food supply chain) to consumers with FHS, to (a) improve consumer confidence in terms of possible allergen content?, and (b) reduce the incidence of unintended allergen exposure? The present research aims to address these questions. This fully powered randomized controlled trial will build on the feasibility study, to investigate whether customers who were proactively asked about allergies or intolerances by staff will report greater perceptions of food safety, confidence that they could tell whether products contain ingredients that they want to avoid consuming, confidence in asking about allergens, and that they will make a greater number of allergens declarations than customers who were not asked proactively.

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