How Restaurant Pros Are Handling the Surge of Food Allergies

Odd Duck prints seven different menus every night customized for diners who are celiac, gluten-free, vegetarian, vegan, tree nut-free, dairy-free, and shellfish-free. And the mole was listed as a safe dish on the nut-free menu. So James grabbed the peanut-free menus and crossed out the mole dish. Then he wound his way through the restaurant, picking off the servers one by one to fill them in on the change. And he also made sure to fill in the host stand, his first line of defense. Crisis averted.

An estimated 15 million Americans have food allergies. And that number is on the rise: a 2013 Centers for Disease Control and Prevention study revealed that food allergies among children increased 50 percent between 1997 and 2011. It's a so far inexplicable phenomenon. Some theories cite a delayed introduction to allergens, the Western diet, and increasing awareness, but non-profit Food Allergy Research & Education notes that "there is no clear answer." Restaurants serve as a landscape upon which all the resulting confusion plays out.

Food allergies are a potentially fatal medical condition that results in more than 200,000 emergency room visits a year.

Outside of Massachusetts and Rhode Island, there is no standardized approach or training requirements for restaurants dealing with food allergies. Instead there's a patchwork of responses that range from accommodating allergies to refusing service. There's plenty of skepticism in between. It's a pretty loose system for a potentially fatal medical condition that results in more than 200,000 emergency room visits a year. Things are even murkier for those with food intolerances or celiac disease, the symptoms of which are only known — sometimes constantly — by the sufferer.

But more restaurants — including Odd Duck — are recognizing there are advantages to accommodating allergies and other dietary restrictions. Here's a look at the landscape through the eyes of Odd Duck.

The No Substitutions Policy

When Odd Duck's critically acclaimed sister restaurant Barley Swine opened in 2010, a familiar phrase was scrawled across the bottom of the menu: "Substitutions and modifications will be politely declined." At the time, Barley Swine had only five chefs working in a small kitchen with a large a la carte menu. The kitchen was willing to bend its no-substitution rule for diners with allergies, James says, but it couldn't afford to go out of its way. Either the cooks could modify the dish easily, or they wouldn't modify it at all. Things were just too crazy.

"At Barley Swine, it was just like put your head down and cook your absolute heart out every night," says Odd Duck chef and partner Mark Buley. "You're doing everything you can to just get the food to the people and trying to push your creative boundary as far as you possibly can."

[Photo: Jessica Pages]

Odd Duck's multi-menu approach to dietary restrictions is somewhat unusual among its peers. Of course, it's not unheard of — José Andrés offers multiple menus at his myriad DC restaurants, as do Ken Oringer and Jamie Bissonnette at Toro in Boston — but it's tough to do. Dietary restrictions can throw kitchens into mayhem with any combination of limited resources, small spaces, a large menu, and that thing that happens when all your diners are placing complex orders at exactly the same time. It's why some restaurants have instituted these no-substitutions policies — and occasionally have earned some flak for them.

Allergy awareness spokesman and chef Ming Tsai is a hardliner when it comes to a restaurant's responsibility to take care of its diners with food allergies and intolerances. His Boston area restaurant Blue Ginger has always taken a detailed approach, using spreadsheets (available for download on his website) that break each dish down by its components, and each component by its ingredients.

It got personal when Ming Tsai's son was diagnosed with seven of the eight most common food allergies.

It got personal when Tsai's son David was diagnosed with seven of the eight most common food allergies (which are milk, eggs, peanuts, tree nuts, fish, shellfish, soy, and wheat). Tsai doesn't excuse chefs and restaurateurs from what he calls their responsibility to serve allergy sufferers. "I know a chef, I'm not going to mention his name, but he has been quoted, 'Hey, if you have peanut allergies, don't come into my f-ing restaurant,'" Tsai says. "I mean, really, dude? What a moron. … He's never EpiPenned his son. He doesn't realize that kids can die." Tsai also famously tells a story of a restaurant whose manager once told him they'd rather not serve his son.

That's on the extreme end of things. Los Angeles restaurant Animal also declines substitutions, but in a more allergen-friendly manner as in Barley Swine's early days. The kitchen — outfitted with two ovens, a fryer, and five cooks on the line — doesn't offer any modifications. As co-owner Jon Shook explains, it's difficult enough to execute the large menu at top speed as it is. "[It] doesn't seem that complicated, but when you're operating a restaurant of our size with the amount of dishes that come off each station, with the amount of opportunity that you could have a four-top come in with all different modifications, to be able to execute those dishes correctly day in and day out without affecting the service and the quality of the product, that is very difficult." It also has something to do with taste: Shook and Dotolo want diners to taste dishes as conceived in order to ensure the quality of that dish.

But Animal and Son of a Gun aren't trying to alienate diners. Shook says that every night's menu is designed with allergies in mind so that everyone should be able to find at least one or two things to order. Servers are trained to guide diners with allergies and other restrictions through the menu. And the whole menu is matrixed out each night with all of the potential allergens and dietary issues for the servers' reference. Though Shook says a fine dining restaurant might just send out an entirely new dish to a diner with allergies, he argues, "That's kind of the same thing we're doing, but we're letting the guest pick."

Sometimes that's really all diners with allergies or sensitivities want. Sloane Miller, food allergy counselor and author of Allergic Girl: Adventures in Living Well With Allergies, says she understands when restaurants need to say no to her. Miller has life-threatening allergies to tree nuts and fish, and says she knows some restaurants just won't be able to serve her safely. But it should be the right kind of no. "That kind of 'no' is not 'We don't serve your kind here,'" Miller says. "It is 'We do not have the facility yet to accommodate you and feel nervous for you, but we want you to stay. How can we make you comfortable?'"

Barley Swine is still technically a no-substitutions restaurant, but a lot has changed since those early days. Now, the restaurant takes reservations for a fixed price shared menu, a changeover that Eater Austin reported occurred just before Odd Duck opened. That most of Barley Swine's seats are now booked in advance means that its cooks have time to ask about dietary issues and prepare before a diner even walks into the restaurant, Buley points out, and the fixed menu eliminates any variables.

But the biggest change in Barley Swine and Odd Duck's approach to dietary restrictions stems from a deliberate management decision to do more.

Why Restaurants Choose to Do More

When Odd Duck opened in December 2013, the management team decided they could do more for dietary requests. They'd all worked together for some time, and Odd Duck's kitchen is larger than the entirety of Barley Swine. Pulling a few cooks off their usual duties doesn't really affect the kitchen so much. "Going from Barley Swine to here is a monstrous difference," James says.

[Photo: Jessica Pages]

But a larger space also brings more diners requesting substitutions and modifications. So each night, someone at Odd Duck would take a copy of the day's menu and a Sharpie, crossing out any dishes with gluten. On another copy of the menu, they would do the same for vegetarian unfriendly dishes, and so on.

It wasn't long until someone complained. About six months after Odd Duck opened, Buley came across a four-star review from a Yelper who raved about the food, but wrote, "I already feel like a tool because I have clinically certified food allergies which has left me somewhat bitter about the cruel hand dealt to me, but I do like to feel as if I'm important enough to have a proper menu printed for me."

And so the restaurant began to print seven separate menus each day.

While it might be easy to dismiss a complaint from Yelp, this particular reviewer wasn't alone. Eater Austin editor Meghan McCarron, who avoids gluten for medical reasons, says that she also felt weird getting a menu full of crossed out dishes at Odd Duck. "Here I am, sharing a bunch of food with people [upon whom] I want to make a good impression," she says, "and I get a menu with big black marks on it that says something like DENIED." But Odd Duck didn't dismiss the Yelper. Buley thought she had a point. And so the restaurant began to print seven separate menus each day.

Odd Duck's commitment goes beyond the menus, too. The Austin restaurant trains its reservationists, hosts, and servers to ask about food allergies and dietary restrictions. If a celiac diner orders quail, the server rings the order in Odd Duck's ticket system, which highlights the allergy in red ink. The expediter calls out that ticket and tells the grill cook not to fire the quail on the grill, which has traces of gluten on its surface. Instead, a sous chef pan-sears the quail. When the server brings the quail to the table, he or she confirms that it is celiac-friendly.

Odd Duck's quail strategy is a textbook example of how to deal with allergies in a restaurant, if such a textbook existed. (More on that in a bit.) Still, this approach is similar to that of other American restaurants that have committed to accommodating dietary restrictions of all kinds.

Danny Meyer's Union Square Hospitality Group tries to "be as athletic as possible" with special requests, says chief restaurant officer Sabato Sagaria. Each restaurant in the group has its own way of handling dietary restrictions, but they all ask about allergies while taking reservations and confirm them at the table. Some restaurants provide special menus for dietary restrictions. Some kitchens have matrices of dishes on the menu noting what allergens they contain. But each kitchen has the group's shared mindset of "finding the yes."

So Maialino — the Roman-style trattoria literally named "piglet" — offers a vegan menu and gluten-free pasta. Director of operations Terry Coughlin says the Maialino team tasted dozens of gluten-free pasta options before landing on one that was up to their standards. When an even better gluten-free pasta came along, Maialino switched to that one. "It's never the server tiptoeing into the kitchen timidly and apologizing for the allergy request," Sagaria says. "The chef has no problem with it because the kitchens have become hard-wired for this kind of thing."

This same mentality runs through a number of American kitchens. The fast-casual segment has moved particularly aggressively toward accommodating allergies. For example, Red Robin and Mellow Mushroom have interactive allergen menus. Chipotle offers an ingredient matrix, too. But, like Danny Meyer, many of the country's best-known chefs and restaurateurs are doing more, too.

José Andrés offers separate menus for tree nut, egg, shellfish, and dairy allergies, as well as gluten-free and vegetarian menus.

Similar to Odd Duck, José Andrés offers separate menus — for tree nut, egg, shellfish, and dairy allergies, as well as gluten-free and vegetarian menus — in his DC restaurants Zaytinya and Jaleo. His Mexican concept Oyamel has a separate "allergy-friendly" menu that marks which dishes can be made without these ingredients. In New York, Mario Batali and Joe Bastianich's Italian fine dining Del Posto is famous for its gluten-free pasta that's so beloved that chef Mark Ladner plans to open a quick-service gluten-free pasta project called Pasta Flyer. And The French Laundry's Thomas Keller partnered with the restaurant's culinary researcher Lena Kwak a few years ago to develop a gluten-free flour that is now available for retail. And, of course, there's Tsai's approach.

"You got to get over yourself, right?" Tsai says. "Thomas Keller, who's probably the best chef in this country, if not the world, he accommodates. He has a vegetarian tasting menu. He can easily do 10 courses vegan if you want, right? He's smart. I think if Thomas Keller can accommodate, every other cook in this world should do it, too."

But how do kitchens become hard-wired for this kind of thing? Odd Duck's Mark Buley figured out some of the tricks the restaurant uses to accommodate allergies just from dining with his sister-in-law, an investor in the restaurant who has celiac disease. "If a bunch of food just gets dropped and the server walks away, she sits there and waits until she figures out what she can and can't eat," he says. Watching that, he realized that a server needs to explain which dishes are allergen-free when setting them down. But other restaurateurs might not have that experience. That's where the question of training comes into play.

Allergy Myths and Training

Odd Duck trains its staff on allergens every day. At the daily staff meetings — usually 20-to-30 minutes long — management will go over the new dishes, their flavors, and also what allergens are in them. Managers teach incoming staff members about each step in the restaurant's allergy plan as seen in the quail example. Odd Duck also keeps a recipe book in which only chefs Gilmore, Buley, and Sam Hellman-Mass record deviations from the standard recipe. The system has never failed. But sometimes, like with the mole made with peanuts, the system cracks.

[Photo: Jessica Pages]

This system is pretty much what restaurants are doing across the country, and its effectiveness depends on the knowledge of the trainers. Which might not always be that reliable. "Most [in-house training programs] likely will not cover food allergens to the degree that we feel it needs to be covered," says Mike Spigler, vice president of education for non-profit group Food Allergy Research & Education.

One anonymous chef claimed that allergies are "mostly total baloney," adding that "ten years ago hardly anyone had a gluten allergy."

Myths persist throughout the restaurant industry when it comes to allergies. Earlier this year, Eater Vancouver asked a string of chefs from the city's "most popular and prestigious restaurants" to anonymously share their complaints about food allergies. Some stories are understandably frustrating: a customer who requested a wheat- and dairy-free dessert only to sneak a bite of a brownie sundae. But other stories reveal a food allergy knowledge gap. One anonymous chef claimed that allergies are "mostly total baloney," adding that "ten years ago hardly anyone had a gluten allergy."

To be fair, hardly anyone did have a gluten allergy ten years ago. No one has ever had a gluten allergy. FARE's website explains that while people can be allergic to wheat, celiac disease is an autoimmune disorder and the more controversial gluten intolerance is a sensitivity issue. But the Mayo Clinic's online research magazine reported in 2010 that celiac disease is four times more common now than it was in 1950. And it wasn't just an increase in diagnoses; researchers found that celiac disease occurred at a smaller rate in 1950 than it does today.

Spigler drops a few more facts: Food intolerance causes varying degrees of stomach discomfort, but an allergy can kill someone. People can be allergic to just about anything, no matter how bizarre, like lettuce or gelatin. Even a microbe of an allergen can provoke a fatal allergic reaction. And there is no such thing as a "mild allergy." An allergy sufferer with a long history of mild reactions, such as hives, could go into the potentially fatal anaphylaxis on their next reaction.

Certain quarters are trying to educate restaurants on these facts. FARE has partnered with the National Restaurant Association on the recently launched ServSafe Allergens online training course ($22), while a second partner, MenuTrinfo, is also offering allergen training for restaurants (starts at $19). Any restaurants whose employees pass the training may then join FARE's searchable database of allergy-friendly restaurants that the organization hopes will provide some extra incentive for restaurants to train employees.

This past January in New York City, Hudson Allergy launched an allergen training course for restaurants that seems to be the first of its kind locally. Dr. Julie Kuriakose and Dr. Tim Mainardi came up with the idea about a year ago in response to their patients' various horror stories. The training is pricier than the online courses, averaging about $1,000 for a two-hour session either on-site or at their practice. So far, the practice has trained a few restaurants in their Tribeca neighborhood, including Gastronomia Culinaria. But the doctors plan to expand out through the city and customize the training sessions to each restaurant, from chains to independents to food carts.

Massachusetts and Rhode Island require restaurants to provide allergen training for their employees.

Massachusetts and Rhode Island have gone even further. Both states require restaurants to provide allergen training for their employees. Massachusetts even specifies the approved vendors for allergen awareness training. Spigler believes "it's inevitable" that more states are headed that way, and points to a 2012 agreement between the US Department of Justice and Lesley University in Massachusetts as evidence that this food allergy legislation could go beyond the states. That agreement, reached after the university had required students to purchase a meal plan without providing gluten-free and allergen-free options, stated that, "Food allergies may constitute a disability under the [Americans with Disabilities Act]."

Odd Duck's system has worked so far, as have allergen self-training programs at restaurants across the country. But no matter how well independent training can work, certified training just might be the direction restaurants are headed with respect to food allergies, whether they like it or not.

The Diner's Responsibility

When James busts out a specially printed gluten-free menu at Odd Duck, people with celiac disease or gluten intolerances sometimes look at him like he's crazy. These menus are a relief for so many diners who are tired of becoming a spectacle every time they order a meal. Not many restaurants provide this kind of relief. But, sometimes, diners might just not be asking.

[Photo: Jessica Pages]

Diners who do have allergies and intolerances have responsibilities here, too. It's up to them to tell a restaurant about allergies or dietary restrictions, even though restaurants like Odd Duck, Blue Ginger, and Maialino have various checkpoints to inquire about it. Maialino's Sagaria describes a scenario in which a diner with a garlic allergy avoids those dishes without telling the waiter, who brings out a gift dish that includes garlic. "Nobody ever got food poisoning from over-communicating," Sagaria says.

It's also useful to share those restrictions in advance, if possible, both allowing the restaurant time to prepare and minimizing any potential embarrassment in front of dining companions. "Don't ever be embarrassed if you have a food allergy. That's stupid. It could kill you. You can't be embarrassed if you can die," Tsai says. "What you can do is your homework and do it in advance so you don't become an embarrassment at a business meeting dinner table. That's your own fault for not prepping."

Diners who don't have food allergies or intolerances are also on the hook. These diners are responsible for not lying about having food allergies or intolerances. Though Odd Duck has a proactive approach to dietary restrictions, it was occasionally frustrating for the kitchen in the beginning. There was that one diner who wanted a gluten-free version of Odd Duck's tater tots. But when warned that this would mean the sauce — which contained flour — would come on the side, the diner walked it back, saying, "Oh, but I'm not really that serious," Buley recalls.

That story is common enough in restaurants. People who don't like mushrooms sometimes claim to be allergic to them in order to get around any no-substitutions policies. People whose personal trainers told them that gluten-free was the fastest way to a flat stomach will claim gluten intolerance, or even celiac disease. Don't do that. Those lies make life a little harder for people who actually do have allergies and intolerances, creating skepticism in a kitchen that has heard it all before.

Even Tsai knows the frustration that comes with a lying guest. "In the end, do we get pissed off a little bit sometimes, sure," Tsai says. "We see people who say, oh I [have a] dairy allergy, and we treat it like that, and boom, then they're eating ice cream for dessert. If I catch it, I'll go to the table and say, look, do us a favor. If you're on a diet, power on. But don't say you have a dairy allergy. That's not fair to us restaurateurs."

When the word "allergy" enters the conversation, any expert will tell you that restaurants can't afford to be skeptical.

But it's worth noting that these cases are not all lies: Someone with an intolerance can sometimes have certain amounts of their restricted item, or might be willing to risk illness for the pleasure of eating something delicious. "I'm sort of in the Anthony Bourdain camp at times where I'd rather get sick from eating that amazing weird fruit in Bali than not have eaten it," Eater Austin's McCarron says. "The problem is I could get sick every day."

And when the word "allergy" enters the conversation, any expert will tell you that restaurants can't afford to be skeptical. Spigler from FARE admits it's possible that someone who dislikes mushrooms might claim to have a mushroom allergy. "But is discounting that worth the risk of killing someone?" he asks. "Absolutely not." Dr. Mainardi of Hudson Allergy further argues that it isn't the job of a restaurant to diagnose a disease. And Miller adds that if a diner mentions an allergy, a restaurant needs "to go into DEFCON mode."

[Photos: Jessica Pages]

Odd Duck's Buley says that it's also just not productive for a restaurant to try to determine whether a diner is lying about an allergy or intolerance. "I think what we all found," he says, "is that you're just going to want to slam your head in the door at the end of the day if you try to discern who's for real and who's just doing it because they want to have a low-carb diet."

Why Cater to People With Allergies?

One compelling reason for accommodating dietary restrictions is that the consequences of ignoring them simply aren't worth it, particularly when it comes to allergies. Most allergy-related deaths occur outside of the home, many of these in restaurants and bars, according to Kuriakose and Mainardi at Hudson Allergy. Even though restaurants can help mitigate these tragedies with increased awareness, Tsai advises diners with allergies to remain vigilant. "The best line you could ever use is, 'I will die if I eat dairy,'" he says. "When you mention the word 'death,' people stand up straighter."

Tsai argues that it just makes good business sense to accommodate allergies and intolerances. "You will never get a more loyal client than someone that has a food allergy, that comes to your establishment, and feels welcome," he says. That loyalty will extend to that client's family, he argues, because the person with food allergies is generally the one calling the shots. That's 15 million Americans making dining decisions for their families and friends.

Society is also more aware of food allergies today — "Everyone has a friend that has a food allergy," says Tsai — prompting more restaurants to look at the cost of accommodating allergy restrictions as an investment in the future. Allergic Girl's Miller says that she's noticed significant changes in restaurants over the last couple of years. "Now there's so much more understanding," she says. "The conversation has opened up." She concurs with Tsai's argument about the economic advantages of accommodating diners with dietary concerns. "I'm loyal, I don't eat alone, and I tip very well," she says.

Beyond allergies, there's another reason restaurants are accommodating dietary restrictions: hospitality. A sign above the pass at Odd Duck reads, "We're in the business of making people's night."

There's another reason restaurants are accommodating dietary restrictions: hospitality.

According to Buley, the restaurant management team's decision to ramp up efforts toward dietary restrictions really came down to customer service. "The last thing any of us want to see is someone have a bad time in the restaurant," he says. "More than once in the dining room, I was like, 'Damn. We could have made that person's night, but we dropped the ball.'"

That's why Buley himself will walk out to a table to help a diner like the woman who couldn't eat any food product that comes from a goat. It's why Odd Duck's kitchen created a whole meal just for the diner with kidney failure who couldn't eat any salt. Odd Duck views all of these potential nuisances as opportunities to make diners feel safe and valued. Which, presumably, would ensure a return visit.

"This kind of stuff makes people's nights," Buley says. "You can put the food in front of them and make them feel secure and confident that what they're eating isn't going to mess with their health. That's a step above the competition."

[Illustration: Eric Lebofsky, inspired by Ox PDX]