NEHA October 2024 Journal of Environmental Health

The October 2024 issue of the Journal of Environmental Health (Volume 87, Number 3), published by the National Environmental Health Association.

JOURNAL OF Environmental Health Dedicated to the advancement of the environmental health professional Volume 87, No. 3 October 2024

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JOURNAL OF Environmental Health Dedicated to the advancement of the environmental health professional Volume 87 No 3 +;ober

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ABOUT THE COVER

Preparing and serving allergen- free meals continues to be challenging for food service establishments. This month’s cover article assessed current

Food Allergy Policies and Procedures in Independently Owned Restaurants in the Orlando Metropolitan Area, Florida ................................................................................. 8

The Impact of Aging on Occupational Lung Disease................................................................ 16

International Perspectives: A New Approach to Examining the Current State of ISO 45001 in the Education Sector: Gap Analysis .................................................................... 26

food allergy policies and procedures in independently owned restaurants in Florida, as well as examined similarities and dier- ences in existing food allergy policies and procedures in those restaurants. The study found that the restaurants accommodated customers who have food allergies, but few restaurants had written food allergy policies and procedures in place. The imagery on the cover highlights the need for policies, proce- dures, and training for both front-of-house and back-of-house employees to protect the health of customers with food allergies. See page 8. Cover images © iStockphoto: SDI Productions/andresr

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Direct From CDC/Environmental Health Services: Disaster Response and Recovery Tools Can Help You Prepare for Emergencies ................................................................. 32

NEW Spotlight on Emerging Professionals: From Internship to Leadership: A Career Journey in Environmental Health .................................................................................. 34

The Practitioner’s Tool Kit: An Alphabet of Values: D, z, and F ................................................... 36

ADVANCEMENT OF THE PRACTITIONER

Environmental Health Calendar ...............................................................................................38

JEH Quiz #2............................................................................................................................... 41

ADVERTISERS INDEX

Spotlight on NEHA Resources: Workforce Outreach Toolkit ....................................................... 42

EHAC-Accredited Programs ................................. 33 EHLR Certificate Program...................................... 7 EMSL Analytical, Inc............................................ 51 Hedgerow Software ................................................2 HS GovTech.......................................................... 52 JEH Advertising ....................................................31 Micro Essential Laboratory, Inc............................ 15 NEHA CP-FS Credential ......................................14 NEHA Credentials ................................................ 25 NEHA Endowment Foundation Donors .............. 40 NEHA Job Board................................................... 39 NEHA Membership ................................................ 4 NEHA REHS/RS Study Guide............................... 39 NEHA/AAS Scholarship Fund Donors ................... 5

YOUR ASSOCIATION

President’s Message: My Thoughts on the NEHA 2024 AEC ................................................................... 6

Special Listing ........................................................................................................................... 44

NEHA News .............................................................................................................................. 46

NEHA 2025 AEC....................................................................................................................... 49

NEHA Member Spotlight .......................................................................................................... 50

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in the next Journal of Environmental Health don’t miss  An Overview of Major Occupational Lung Diseases  Extended-Spectrum Beta- Lactamase (ESBL) E. coli Compartment Bag Test Method in Comparison to the World Health Organization Tricycle Protocol  Qualitative Renement of a Tickborne Disease Survey  Plus, the NEHA 2024 AEC Wrap-Up

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An open access journal published monthly (except bimonthly in January/ February and July/August) by the National Environmental Health Association (NEHA), 720 S. Colorado Blvd., Suite 105A, Denver, CO 80246-1910. Phone: (303) 802-2200; Internet: www.neha.org. E-mail: jeh@neha.org. Volume 87, Number 3. Yearly print subscription rates: $160 (U.S.) and $200 (international). Single print copies: $15, if available. Claims must be filed within 30 days domestic, 90 days foreign, © Copyright 2024, NEHA (no refunds). Opinions and conclusions expressed in articles, columns, and other contributions are those of the authors only and do not reflect the policies or views of NEHA. NEHA and the Journal of Environmental Health are not liable or responsible for the accuracy of, or actions taken on the basis of, any information stated herein. NEHA and the Journal of Environmental Health reserve the right to reject any advertising copy. Advertisers and their agencies will assume liability for the content of all advertisements printed and also assume responsibility for any claims arising therefrom against the publisher. Advertising rates available at www.neha.org/jeh. The Journal of Environmental Health is indexed by Clarivate, EBSCO (Applied Science & Technology Index), Elsevier (Current Awareness in Biological Sciences), Gale Cengage, and ProQuest. The Journal of Environmental Health is archived by JSTOR (www.jstor.org/journal/ jenviheal). Full electronic issues from present to 2012 available at www.neha.org/jeh. All technical manuscripts submitted for publication are subject to peer review. Visit www.neha.org/jeh for submission guidelines and instructions for authors. To submit a manuscript, visit https://jeh.msubmit.net. Direct all questions to jeh@neha.org. Periodicals postage paid at Denver, Colorado, and additional mailing offices. POSTMASTER: Send address changes to Journal of Environmental Health , 720 S. Colorado Blvd., Suite 105A, Denver, CO 80246-1910.

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Volume 87 • Number 3

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October 2024 • Journal of Environmental Health

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Open Access

 PRESIDENT’S MESSAGE

My Thoughts on the NEHA 2024 AEC

CDR Anna Khan, MA, REHS/RS

I t was an honor and a pleasure to at- tend and take part in the National Envi- ronmental Health Association’s (NEHA) Annual Educational Conference (AEC) & Exhibition in Pittsburgh, Pennsylvania, in July. Despite the many changes our world is going through, it was comforting to find one constant—the dedicated, bright, and profes- sional members of our environmental health community from around the world all in one place. I am inspired by the current and future leaders in environmental health who I had the privilege to talk with and hear their stories. There were environmental health students and practitioners that I met for the first time who shared their stories about why they are in environmental health. I was amazed by the adventurous stories of a lieutenant in the U.S. Public Health Service who is working in Alaska and traveling by plane to support communities across the state. She is learning about diverse cultures as well as solving dif- ferent environmental challenges and address- ing the impacts of weather and climate change that each community encounters. I met with two environmental health stu- dents who shared their stories with me. The first student explained how a hurricane had destroyed her home and the emotional impact it had on her and her family. She talked about public health messaging and the importance of environmental public health. The second student studied abroad. We talked about how some developing countries recognize the importance of environmental health, specifically water, sanitation, and food safety. We also talked about issues that we struggle with today in a developed country, such as

and make their day, tell them climate change does not exist. They will flash a wise, all- knowing smile, explain why it does, and immerse you in data. These conversations also brought up one of the key elements that I will continue to work on during my presidency, which is how we address the strain on our current work- force and what are we doing about workforce challenges. A recent article discusses the workforce as one of the changes that we need to overcome (Chamberlain et al., 2024). In the article, Emory University and the Georgia Department of Health recognized the need for epidemiologists in the field. They collabo- rated and created an epidemiology fellowship in 2020 to fill the gap across Georgia. Ideas such as this one help us move the needle in the direction that we need to go. NEHA is also thinking outside the box about how to help environmental health students and how to support new professionals in their careers. I look forward to providing more information in the next few months. I also want to mention that during the 2024 AEC, there was a session titled, “Rais- ing the Environmental Health Voice.” This session was led by Chana Goussetis, direc- tor of marketing and communications at NEHA. She provided communication strate- gies for environmental health professionals in the field. This guidance provides support to environmental health professionals when communicating with decision-makers about what they do, why it is important, and creat- ing a call to action to keep our communities safe. You can find this tool kit of resources at www.neha.org/workforce-outreach-toolkit.

NEHA is reaching out, embracing more environmental health professionals, connecting subject matter experts, and strengthening us as a profession.

the importance of pasteurization. These con- versations reminded me that each time we step into a new critical project and each time we work in a domestic or global community, we are likely helping communities during a vulnerable and challenging time. We might not understand exactly what they are going through, but we enter their world with empa- thy, kindness, and a willingness to help move things forward so they have some stability back in their lives. I had the opportunity to listen to some of our wisest (i.e., been around the block a few times) environmental health professionals. I learn something new in every conversa- tion with them. I enjoy their advocacy and willingness to stand up and say something when newer professions may feel the need to tip-toe around certain subjects. I refer to them as our Clint Eastwoods. Yes, go ahead

Volume 87 • Number 3

We have also highlighted the tool kit in this issue on pages 42 and 43. I would be remiss if I did not mention the backbone of our organization, our unsung heroes, the NEHA sta. We would not be able to reach our members and beyond if it were not for them. We would not have our grants or our outreach if it were not for them. And we would not have our amazing conference where we can connect with colleagues, men- tors, and students from across the globe; learn from one another; and grow as professionals if it were not for them. Due to their hard work and dedication, we had our largest AEC this year with more than 19 rooms showcasing more than 300 sessions. Because of them,

we have the highest number of NEHA mem- bers—over 7,100. We have an open-access journal now with an 80% increase in viewers. What does this all mean? It means that NEHA is reaching out, embracing more envi- ronmental health professionals, connecting subject matter experts, and strengthening us as a profession. NEHA’s legacy is its members—past, pres- ent, and future. It is inspiring to see the diver- sity of NEHA, which is indeed its strength. We come from a wealth of backgrounds, perspectives, subject matter expertise, expe- rience levels, and skill sets. And it makes me proud to see NEHA’s diversity coming together under a united front of commitment

to advance the environmental health of all communities across the globe.

Reference Chamberlain, A.T., Rentmeester, S.T., Rose, E., Fletcher, G., Drenzek, C., Pavlick, J.G., Curran, J.W., & Toomey, K.E. (2024). Suc- cess of the Rollins Epidemiology Fellow- ship in rebuilding Georgia’s epidemiologic workforce. Health Aairs , 43 (6), 831–839. https://doi.org/10.1377/hltha.2023.01652 akhan@neha.org

The NEHA/AAS Scholarship is available to undergraduate and graduate students enrolled in an accredited college or university with a dedicated and recognized curriculum in environmental health sciences. The scholarships encourage an early commitment by students to pursue a career in environmental health. Consider donating today to support the next generation of environmental health professionals. Learn more at www.neha.org/donate.

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326756-B

Get certified in environmental health and land reuse and help reduce health disparities in your community. Visit neha.org/ehlr. Close the gap.

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VNN$ $ SCIENCE

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Food Allergy Policies and Procedures in Independently Owned Restaurants in the Orlando Metropolitan Area, Florida

Nelson M. Placa, PhD Department of Apparel, Events, and Hospitality Management, Iowa State University Anirudh Naig, PhD Department of Apparel, Events, and Hospitality Management, Iowa State University

tamination. Gupta et al. (2019) suggested training restaurant managers and employ- ees about food allergies, including how to communicate food allergen information to consumers. Food service employees might have access to menu ingredient informa- tion and/or know about food allergy risks to accommodate customers who have food allergies (McAdams et al., 2018), but this might not always be the case. Wen and Kwon (2016) suggested improving commu- nication between employees and consumers can help reduce risks by enabling employees to provide accurate information to custom- ers about allergens in menu items. Shaw (2019) suggested food service opera- tions should be willing to modify menu items, use alternate ingredients, and use separate equipment to accommodate cus- tomers who have food allergies. Lee and Xu (2015) found food service employees willing to modify recipes to accommodate customers who have food allergies. Providing allergen- free foods to consumers who have food aller- gies, however, remains a challenge (Wen & Kwon, 2016). Challenges include hid- den allergens, food preparation techniques, lack of resources (e.g., gloves, space, time), untrained employees or lack of employee knowledge about food allergies, and cost. Of note, Harris (2017) found chain restaurants followed food safety practices more often than independently owned restaurants. Illinois, Maryland, Massachusetts, Michi- gan, Rhode Island, Texas, Virginia, and two U.S. cities (New York City, New York, and St. Paul, Minnesota) have legislation for train- ing food service employees about food aller- gies to safeguard customers who have food allergies (FARE, 2024). Florida’s Division of Hotels and Restaurants requires all food operators and employees to know and name

b:;r)+; Preparing and serving allergen-free meals continue to be challenging for food service establishments due to the associated costs and complexity of menu items. Our study assessed food allergy policies and procedures in independently owned restaurants ( n = 103) within the Orlando metropolitan area in Florida. The Florida Department of Business and Professional Regulation HR 5030-038 from the Division of Hotels and Restaurants requires all food service managers and employees to know and name the top 8 major allergens and describe common food allergy symptoms. In total, 71 restaurants accommodated customers who have food allergies. Further, 25 restaurants reported having written food allergy policies and procedures, 63 did not, and 5 did not know. Approximately one half (49) of the owners, operators, and managers did not receive food allergy training. Of the training provided, 27 restaurants oered training in English and 20 restaurants oered training also in Spanish. Food service establishments will benefit from developing and implementing food allergy policies and procedures to serve food safely to customers who have food allergies. Keywords: food service, food allergy, policies and procedures, independently owned restaurant

Introduction A food allergy is an immune system reaction to proteins in food and can cause life-threat- ening situations. Food allergies aect 33 million individuals (Food Allergy Research & Education [FARE], 2023). A food allergy is considered a disability under the Ameri- cans With Disabilities Act and Section 504 of the 1973 Rehabilitation Act (U.S. Depart- ment of Justice Civil Rights Division, 2020). The U.S. food service industry accounts for 50% of the dollars consumers spend on food (U.S. Department of Agriculture, 2022). Pro- viding safe food is the responsibility of all food service establishments and is essential to protect public health. Providing safe food

also prevents lawsuits, financial losses, and business closures. Lee and Sözen (2016) found a lack of knowledge and training regarding food allergies among employees at indepen- dently owned and chain restaurants, includ- ing front-of-house (e.g., host, server) and back-of-house (e.g., kitchen) sta. Despite employee interest in learning about food allergies, 63% of employees had not received food allergy training. A study by Soon (2018) found food service employees in takeout restaurants lacked an understand- ing of the dierence between food allergies and food intolerances, as well as food han- dling practices needed to avoid cross-con-

Volume 87 • Number 3

Most research in food service about food allergies has centered on assessing employee food allergy knowledge, attitudes, and prac- tices. Few research studies have assessed food allergy policies and procedures. In our study, we a) assessed current food allergy policies and procedures in independently owned res- taurants and b) examined similarities and dif- ferences in existing food allergy policies and procedures in independently owned restau- rants in the Orlando metropolitan area.

TABLE 1

Demographic Characteristics of Participating Independent Restaurant Owners, Operators, and Managers ( n = 103)

Characteristic

Gender

Male

65 36

63.1 35.0

Female

Prefer not to answer

1 1

1.0 1.0

Methods

Not answered

Age (years) 18–25

Sample Selection Owners and managers of independently owned restaurants in the Orlando metropoli- tan area were the target population for our study. We chose this area because of its popu- lation size of 2.6 million (U.S. Census Bureau, 2022) and because it is a popular tourist des- tination. In 2022, approximately 74 million tourists visited the area (VisitOrlando.org, 2024). We obtained a list of independently owned restaurants ( n = 1,123) from the Florida Department of Business and Profes- sional Regulation (DBPR), Division of Hotels and Restaurants website. We reviewed and updated the list to include restaurant type and cuisine type and verified the information with restaurant owners, operators, and man- agers via phone call or the restaurant website. At the time of data collection, the COVID-19 pandemic caused >100,000 restaurants in the U.S. to close either permanently or tempo- rarily, which resulted in the closure of many restaurants in the Orlando metropolitan area (National Restaurant Association [NRA], 2024; Yelp, 2020). After accounting for per- manent ( n = 78) and temporary ( n = 88) clo- sures, 957 restaurants remained eligible to participate in our study. We contacted restaurant owners or man- agers ( n = 957) by telephone to explain the purpose of our study. Owners, operators, and managers who agreed to participate were asked to provide their email addresses to be sent the electronic questionnaire. A total of 41 restaurants declined to participate and 255 did not respond. Overall, 661 restaurants provided email addresses, of which 60 were undeliverable, resulting in a final sample size of 601. The institutional review board at Iowa State University approved the data collection protocol and questionnaire.

10 33 30 13 16

9.7

26–33 34–41 42–49

32.0 29.1 12.6 15.5

≥50

Not answered

1.0

Race

Hispanic or Latinx

42 39 11

41.0 37.9 10.7

White

Black or African American

Asian

8 1 1 1

7.8 1.0 1.0 1.0

American Indian or Alaska Native

Prefer not to answer

Not answered

Highest level of education High school or GED

15 24 20 34

14.6 23.3 19.4 33.0

Some college

Associate degree Bachelor’s degree Master’s degree Doctoral degree

8 1 1

7.8 1.0 1.0

Not answered

First language English

63 35

61.2 34.0

Spanish

Other

2 1 1 1

1.9 1.0 1.0 1.0

Chinese

Haitian Creole Not answered

continued 

the top 8 major allergens included on form HR 5030-038 and to recognize food allergy symptoms (Florida Department of Business and Professional Regulation [DBPR], 2015).

The number of Florida restaurants that lack food allergy policies and procedures is unknown, which presents a risk to customers who have food allergies.

October 2024 • our6)l o. 6=1ro6me6;)l e)l;0

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Questionnaire We adapted the questionnaire developed and validated by Abdelmassih et al. (2016) and col- lected demographic information. Experts in food safety, food service, and research design ( n = 5) reviewed the questionnaire for validity and clarity before pilot testing. The questionnaire was translated into Spanish and then translated back into English to check for accuracy. Pilot Study We piloted the revised questionnaire with five owners, operators, or managers of inde- pendently owned Orlando metropolitan area restaurants. The pilot questionnaire included 1 open-ended and 11 multiple-choice ques- tions to assess language clarity for English and Spanish, survey design, and flow. Data Collection and Analysis After pilot testing, we used the survey plat- form Qualtrics to collect questionnaire responses electronically. The Florida DBPR Division of Hotels and Restaurants has an online directory of restaurants in Florida. Based on this directory, we communicated with restaurant owners, operators, and man- agers to explain that participation was volun- tary and would not aect their employment status. Participants could refuse or discon- tinue participation at any time and would still be able to enter the drawing for gift cards. We sent participants three reminder emails. Data were analyzed using SPSS version 27.0.

TABLE 1 continued

Demographic Characteristics of Participating Independent Restaurant Owners, Operators, and Managers ( n = 103)

Characteristic

Owned or managed current restaurant (years) <1

12 59 15

11.7 57.3 14.6

1–5

6–10

11–15

4.9

≥16

10.7

Not answered

1.0

Food service experience (years) <1

1.0

1–5

43 24 14 20

41.8 23.3 13.6 19.4

6–10

11–15

≥16

Not answered

1.0

Restaurant type

Casual (full service)

40 35 13 10

38.8 34.0 12.6

Quick service

Fine dining (full service)

Takeout and delivery

9.7 3.8 1.0

Other

4 1

Not answered

Type of cuisine American

42 31 10

40.8 30.1

Latinx (e.g., Mexican, Puerto Rican, Venezuelan)

Results

Italian

9.7 4.9 1.0 1.0 1.0

Chinese

5 1 1 1

Demographic Characteristics In total, 111 questionnaires were returned with a response rate of 19%. Of these ques- tionnaires, we eliminated eight incomplete submissions (Table 1). According to the U.S. Bureau of Labor Statistics (2020), female employees make up the majority (53%) of the food service industry workforce, but in our study, most respondents were male employ- ees ( n = 65, 63%). Nearly one third of par- ticipants were in the age range 26–33 years ( n = 33, 32%), corresponding with the aver- age employee age of 31.6 years (U.S. Bureau of Labor Statistics, 2020). Moreover, more than one third of participants were Hispanic or Latinx ( n = 42, 41%), which is higher than the national number (26%) in the U.S. restau- rant industry (NRA, 2024).

Indian

Japanese

Vietnamese

Other (e.g., French, Haitian, Jamaican, Spanish, Thai)

10.7

Not answered

1.0

English was the most commonly spoken first language ( n = 63, 61%), followed by Spanish ( n = 35, 34%). Moreover, 43 par- ticipants (42%) had 1–5 years of experience working in a food service establishment. Fur- ther, 59 participants (58%) had 1–5 years of experience owning or managing a food ser- vice establishment. American cuisine was the most commonly represented cuisine ( n = 42, 41%), followed by Latinx cuisine ( n =

31, 30%). Full-service casual operations ( n = 40, 39%), were slightly more common than quick-service operations ( n = 35, 34%). Food Allergy Policies and Procedures Most participants ( n = 85, 83%) reported zero occurrences of allergic reaction in a customer in their restaurant. Fewer than one in five ( n = 15, 18%) acknowledged at least one patron had suered an allergic reaction

Volume 87 • Number 3

in their restaurant. Most participants ( n = 72, 69%) accommodated customers who have food allergies, while nearly one third ( n = 31, 30%) did not. Of the participants, less than one half ( n = 41, 40%) identified allergen-free menu items for customers with a food allergy, whereas more than one half ( n = 68, 59%) did not. Further, nearly two thirds of participants ( n = 63, 61%) indicated their restaurant had no written food allergen policies and proce- dures. Participants at food service establish- ments with written food allergy policies and procedures indicated having policies and pro- cedures in place for 1–3 years ( n = 20, 19%). In our study, more than one half of par- ticipants had received formal food allergy training. Specifically, 62% of owners, opera- tors, and managers ( n = 64) and 54% of back- of-house employees ( n = 56) had received formal food allergy training. Additionally, more than one half of the participants ( n = 60, 58%) had some food safety certification. The Florida DBPR has adopted the 2017 ver- sion of the Food and Drug Administration Food Code (FDA, 2022). Section 381.0072 of the Florida statutes requires all food ser- vice establishments to have a certified food manager at the food service establishment (Florida DBPR, 2024). More than one half ( n = 53, 52%) of participants had not received any food allergy training, and most ( n = 80, 78%) were not certified in food allergy train- ing (Table 1). The Florida DBPR does not require food service operations to provide thorough food allergy training to operators and employees but requires that employees know and be able to name the top 8 major allergens and recognize common food allergy symptoms (Florida DBPR, 2015). Of the participants, more than one half ( n = 66, 64%) responded no to having food allergy training offered in multiple lan- guages. Participants who answered yes to having training available in multiple lan- guages selected Spanish ( n = 20, 19%) as the second-most common language after Eng- lish. More than one half of participants ( n = 55, 53%) had designated individuals (e.g., manager, host, server, cook) who could explain allergen-free menu options to cus- tomers with a food allergy. Owners, opera- tors, and managers ( n = 43, 42%) usually were the designated person to communi- cate allergen-free menu options to custom- ers who have a food allergy, followed by the

TABLE 2

Food Safety Policies and Procedures for Independently Owned Restaurants ( n = 103)

Policy and Procedure

Does your restaurwant accommodate customers with food allergies? Yes

71 31

68.9 30.1

Do not know 1.0 If yes is selected, which of the following food allergy-free menu items do you have available at your restaurant? Select all that apply.* Gluten-free 37 35.9 Peanut- or nut-free 29 28.2 Milk-free 18 17.5 Soy-free 16 15.5 Shellfish-free 20 19.4 Egg-free 20 19.4 Other (e.g., corn-free) 5 4.9 Does your restaurant currently have written food allergen policies and procedures in place? Yes 35 34.0 No 63 61.1 Do not know 5 4.9 If yes is selected, how long have these written food allergen policies and procedures been in place? (years) <1 5 4.9 1–3 20 19.4 4–6 6 5.8 >6 7 6.8 Not answered 65 63.1 Does your restaurant currently have formal food allergy training? Select all that apply.* Yes 19 18.5 No 66 73.8 Do not know 17 16.5 Owner or manager 64 62.1 Front-of-house (e.g., host, server) 29 28.3 Back-of-house (e.g., cook, chef) 56 54.4 In which language(s) is the training available? Select all that apply.* English 27 26.2 Spanish 20 19.4 Portuguese 1 1.0 Haitian Creole 3 2.9 Chinese 1 1.0 Does your restaurant have a designated individual (e.g., manager, host, server, cook) who can explain allergen-free menu options to customers who have a food allergy? Yes 55 53.4 No 45 43.7 Do not know 3 2.9 1

continued 

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cook/chef ( n = 35, 34%) and servers ( n = 24, 23%). Participants reported that hosts ( n = 83, 81%) and servers ( n = 67, 65%) were not required to ask customers if they needed food allergy accommodations. Wen and Kwon (2016) suggested that training food service employees on proper communication with customers who have food allergies influenced risk-reduction behaviors of the employees. In our study, most participants ( n = 92, 89%) reported communication between front-of-house and back-of-house sta about customers’ food allergy accommodation. Further, most front- of-house and back-of-house kitchen sta ( n = 96, 93%) reported that they worked together to provide allergen-free meals to customers with food allergies. Additionally, more than one half of employees ( n = 63, 61%) reported that they were required to contact the man- ager or supervisor with questions about avail- able food allergy accommodations. Yet more than one half of participants ( n = 55, 51%) described not having an emergency plan if a customer had an allergic reaction in the res- taurant (Table 2). Discussion Our study examined similarities and dif- ferences between food allergy policies and procedures in independently owned Orlando metropolitan area restaurants. We found that almost two thirds of partici- pants accommodated customers who have food allergies, and one third of participants identified allergen-free menu items for cus- tomers with food allergies. Fewer than one half of the independently owned restau- rants had written food allergy policies and procedures. A study of front-of-house and back-of-house employees from chain ( n = 123) and independently owned ( n = 106) restaurants in the U.S. found that 82% of employees had policies for accommodat- ing consumers who have food allergies and 38% of employees had received food allergy training (Lee & Sözen, 2016). The authors did not specify, however, whether policies were more prevalent in chain or indepen- dently owned restaurants. Studies con- ducted with college and university dining food service operations also found a lack of uniform food allergy policies and proce- dures (Abdelmassih et al., 2016; Rajagopal & Strohbehn, 2011).

TABLE 2 continued

Food Safety Policies and Procedures for Independently Owned Restaurants ( n = 103)

Policy and Procedure % If yes is selected, who is the individual who communicates allergen-free menu options to customers who have a food allergy? Select all that apply.* Manager or owner 43 41.8 Host 6 5.8 Server (i.e., food handler) 24 23.3 Cook or chef 35 34.0 Is the host required to ask customers if they need food allergy accommodations? Yes 15 14.6 No 83 80.6 Do not know 5 4.6 Is the server required to ask customers if they need food allergy accommodations? Yes 34 33.0 No 67 65.0 Do not know 2 1.9 Is the host required to notify the server about customers who need food allergy accommodations? Yes 52 50.5 No 49 47.6 Do not know 2 1.9 Is the server required to notify back-of-house employees (i.e., kitchen staff) about customers who need food allergy accommodations? Yes 92 89.3 No 10 9.7 Do not know 1 1.0 Are employees required to contact the manager or supervisor for questions about available food allergy accommodations? Yes 63 61.2 No 38 36.9 Do not know 2 1.9 Do front-of-house and back-of-house employees work together to provide allergen-free meals to customers who have a food allergy? Yes 96 93.2 No 4 3.9 Do not know 3 2.9 Is there an emergency action plan in case a customer has an allergic reaction in the restaurant? Yes 44 42.7 No 52 50.5 Do not know 7 6.8 #

*Percentages add up to >100 because respondents could select multiple answers.

In our study, more than one half of par- ticipants indicated not having an emergency action plan if a customer has an allergic reac-

tion in their restaurant. Wham and Sharma (2014) noted that despite having a high level of confidence that managers can handle a

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food allergy emergency, restaurant manager participants demonstrated a lack of knowl- edge in identifying and managing allergen risks. Furthermore, restaurant manager par- ticipants who had received food allergy train- ing were more likely to have an action plan in place to accommodate customers who have food allergies and implement an action plan in case of an allergic reaction in the restau- rant (Wham & Sharma, 2014). To reduce incidents of allergic reactions to food in restaurants, owners should imple- ment food allergy training that includes an action plan for if a customer has an aller- gic reaction (Wen & Kwon, 2016). Further, Madera et al. (2013) concluded that employ- ees with limited English ability received inad- equate training because most training is not presented in their primary language. Provid- ing food safety educational materials in rele- vant languages other than English is essential to minimizing food safety risks (Rajagopal, 2013). Moreover, implementing policies and procedures to accommodate customers who have food allergies could prevent many aller- gic reactions to food in restaurants. Our study had several potential limita- tions. It was conducted 3 months into the COVID-19 pandemic, and the resulting tem- porary and permanent restaurant closures had a large impact on our data collection pro- cedures and access to the sample population. Participants remained anonymous, which made it dicult to determine if multiple par- ticipants from the same restaurant had par-

ticipated in the study. Moreover, because the study was conducted during the pandemic, owners or managers might have had a height- ened awareness of food safety and sanitation procedures. And lastly, social desirability bias might have also influenced participants, as data were self-reported. Conclusion Our study found that restaurants in the Orlando metropolitan area accommodated customers who have food allergies, but few restaurants had written food allergy policies and procedures in place. Written policies and procedures ensure all employees handle accommodation requests for food allergies similarly. The absence of written policies and procedures can lead to dierences in how employees handle food allergy accom- modations, resulting in life-threatening con- sequences. Only seven states and two cities in the U.S. require commercial food service establishments to accommodate consumers who have food allergies and provide employ- ees with food allergen awareness training (FARE, 2024; Nienstadt, 2016). In Florida, there are no laws to protect con- sumers with food allergies or require employ- ees to receive training on food allergies. Implementing legislation to standardize and improve safety and awareness in restaurants about food allergies could reduce risk to con- sumers in Florida and other states. To this aim, FARE (2024) has developed a Restaurant Leg- islation Toolkit that provides guidelines and

resources to advocate for legislation in states that do not have laws regarding food allergies. Additionally, restaurants should consider adding food allergen awareness posters in English and Spanish in prominent locations to assist food service employees in accommodat- ing customers who have food allergies. Fur- ther, owners, operators, and managers should consider developing and implementing stan- dard food allergy policies and procedures to reduce the risk of a food allergy incident. Future studies could investigate factors that influence the development and implementa- tion of food allergy policies and procedures in independently owned restaurants. Additional studies could use questionnaires and focus groups to evaluate perceived motivators and barriers of restaurant employees, which could inform the development and implementation of food allergy policies and procedures. Findings from our study can be used to inform legislators in Florida about developing and implementing food allergy laws. Further development and implementation of food allergy policies, procedures, and employee training—independent of food allergy leg- islation status at the state level—will enable food service establishments to better protect customers who have food allergies. Corresponding Author: Anirudh Naig, Depart- ment of Apparel, Events, and Hospitality Man- agement, Iowa State University, 31 Mackay Hall, Ames, IA 50011. Email: anaig@iastate.edu

References

Abdelmassih, K., Rajagopal, L., & Arendt, S.W. (2016). A mixed methods approach to examining food allergy accommodation eorts in colleges and universities. The Journal of Foodservice Management and Education , 10 (2), 26–34. Florida Department of Business and Professional Regulation. (2015). Division of Hotels and Restaurants–Food allergen awareness. https:// www2.myfloridalicense.com/hr/forms/documents/5030_038.pdf Food Allergy Research & Education. (2023). Living with food allergies: Food allergy 101 . https://www.foodallergy.org/living-food-allergies/ food-allergy-essentials/food-allergy-101 Food Allergy Research & Education (2024). Food allergies and food service establishments. https://www.foodallergy.org/our-initiatives/ advocacy/know-your-rights/food-allergies-and-restaurants Food and Drug Administration. (2022). Draft guidance for industry: Questions and answers regarding food allergen labeling (Edition 5).

https://www.fda.gov/regulatory-information/search-fda-guidance- documents/draft-guidance-industry-questions-and-answers- regarding-food-allergen-labeling-edition-5 Gupta, R.S., Warren, C.M., Smith, B.M., Jiang, J., Blumenstock, J.A., Davis, M.M., Schleimer, R.P., & Nadeau, K.C. (2019). Prevalence and severity of food allergies among U.S. adults. JAMA Network Open , 2 (1), e185630 https://doi.org/10.1001/ jamanetworkopen.2018.5630 Lee, Y.M. & Sözen, E. (2016). Food allergy knowledge and train- ing among restaurant employees. International Journal of Hos- pitality Management , 57 , 52–59. https://doi.org/10.1016/j.ijhm. 2016.05.004 Lee, Y.M. & Xu, H. (2015). Food allergy knowledge, attitudes, and preparedness among restaurant managerial sta. Journal of Food-

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service Business Research , 18 (5), 454–469. https://doi.org/10.1080 /15378020.2015.1093452 Madera, J.M., Dawson, M., Neal, J.A., & Busch, K. (2013). Break- ing a communication barrier: The eect of visual aids in food preparation on job attitudes and performance. Journal of Hospitality & Tourism Research , 37 (2), 262–280. https://doi. org/10.1177/1096348012436376 McAdams, B., Deng, A., & Maclaurin, T. (2018). Food allergy knowledge, attitudes, and resources of restaurant employees. Brit- ish Food Journal , 120 (11), 2681–2694. https://doi.org/10.1108/ BFJ-01-2018-0028 National Restaurant Association. (2024) . National statis- tics: Get the facts with the latest National Statistics. https:// restaurant.org/research-and-media/research/industry-statistics/ national-statistics/ Nienstadt, A. (2016). The insuciency of the law surrounding food allergies. Pace Law Review , 36 (2), 595–623. https://doi. org/10.58948/2331-3528.1924 Rajagopal, L. (2013). Educating immigrant Hispanic foodservice workers about food safety using visual-based training. Journal of Extension , 51 (2), 1–16. Rajagopal, L. & Strohbehn, C.H. (2011). Views of college and uni- versity dining directors on food allergen policies and practices in higher education settings. Journal of Foodservice Management and Education , 5 (1), 15–21. Shaw, F. (2019). Elevating restaurant food allergy protocols. https:// www.modernrestaurantmanagement.com/elevating-restaurant- food-allergy-protocols/

Soon, J.M. (2018). ‘No nuts please’: Food allergen management in takeaways. Food Control , 91 , 349–356. U.S. Bureau of Labor Statistics. (2020). Labor force statistics from the Current Population Survey . https://www.bls.gov/cps/cps_over.htm U.S. Census Bureau. (2022). American Community Survey 1-year estimates [Census Reporter Profile page for Orlando-Kissimmee- Sanford, FL Metro Area] . http://censusreporter.org/profiles/ 31000US36740-orlando-kissimmee-sanford-fl-metro-area U.S. Department of Agriculture. (2022). Economic research service: Food away from home. https://www.ers.usda.gov/topics/food- choices-health/food-consumption-demand/food-away-from- home.aspx U.S. Department of Justice Civil Rights Division. (2020). Guide to disability rights laws . https://www.ada.gov/resources/disability- rights-guide/ VisitOrlando.org. (2024). Data and trends . https://www.visitorlando. com/media/research/orlando-data/ Wen, H. & Kwon, J. (2016). Food allergy risk communication in restaurants . Food Protection Trends , 36 (5), 372–383. Wham, C.A. & Sharma, K.M. (2014). Knowledge of café and res- taurant managers to provide a safe meal to food allergic con- sumers . Nutrition & Dietetics , 71 (4), 265–269. https://doi. org/10.1111/1747-0080.12104 Yelp. (2020). Increased consumer interest in May correlates with COVID-19 hot spots in June, according to the Yelp economic average. https://www.yelpeconomicaverage.com/yea-q2-2020.html

Did You Know?

Sign up for our virtual CP-FS Credential Exam Prep Course in October to help focus your studies and prepare you for the exam. The course will be on October 22, 23, 29, and 30. Register today at www.neha.org/cpfs-vilt.

The food industry moves fast. The Certified Professional–Food Safety (CP-FS) credential keeps you up-to-date with the rapidly changing food industry and tells your community that you know the science and practice to keep them safe. Learn the requirements: neha.org/cpfs-credential

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