Navigating the Big 9: Managing Food Allergies in Healthcare Settings

According to the FDA, the Big 9 allergens include:

• Milk
• Eggs
• Fish (e.g bass, flounder, cod)
• Crustacean shellfish (e.g. crab, lobster, shrimp)
• Tree nuts (e.g. almonds, walnuts, pecans)
• Peanuts
• Wheat
• Soybeans
• Sesame (officially added in 2023)

These ingredients can appear in surprising places, from medications and nutritional supplements to texture-modified foods and fluids and meal replacements. It is essential to read ingredients and be aware of the products that include these allergens. For example, soybean oil in salad dressings, whey in high protein powders or nutritional supplements, nuts in packaged muffins, granola bars, etc.

1. Clear Documentation: If an individual has a food allergy or allergies, these should be identified and documented on the meal identification (ID) card/ticket, medical record, dietary orders, and care plans. Facilities may also use wristbands to identify residents/patients with food allergies. Any food can cause an allergic reaction, so details are essential. For example, some people may be allergic to fish, while others are allergic to shellfish. If a new allergy is identified, updates should be made immediately.
2. Staff Training: All staff – clinical, food and nutrition services, and support staff – should receive regular training on identifying allergens, reading labels, and knowing what to do in an emergency. Additional training/communication should occur when a new patient/resident is admitted with any allergy.
3. Special Menu: Individuals with severe food allergies should be offered a specialized menu that excludes the 9 major allergens and emphasizes whole food items for safe self-selection.
4. Accurate Meal Preparation: Kitchen and food and nutrition services teams should have systems in place to prevent cross-contact, such as:
   • Dedicated allergy-free food preparation areas
   • Use equipment that is designated solely for preparing or serving foods containing any of the Big 9 allergens (i.e. color coded cutting boards, using separate tongs or utensils)
   • Strict sanitation practices between tasks
5. Appropriate Substitutions: According to the Centers for Medicare & Medicaid Services (CMS) State Operations Manual Appendix PP – Guidance to Surveyors for Long Term Care Facilities (Rev 225; Issued: 08/08/24) , facilities must know each resident’s allergies, intolerances, and food preferences and offer suitable alternatives as needed. Substitutes should align with the facility’s standard offerings. For example, grapefruit juice can be replaced with another citrus or vitamin C-rich juice the resident prefers.
6. Label Reading and Ingredient Tracking: Even if a food seems safe, ingredient lists must be checked thoroughly every time. Manufacturers can change recipes without notice, and hidden allergens are common. To learn more about food labeling, refer to this USDA document.
7. Resident and Patient Education: When appropriate, support patients and residents in actively participating in their care by asking questions and confirming ingredients when uncertain. Utilize this chart for appropriate substitutions.
8. Regulatory Inspections: Knowing what to expect during a Joint Accreditation or CMS State survey inspection ensures compliance with regulatory standards and safe food service practices. For CMS state survey standards regarding allergies, preferences, and intolerances, refer to the Nutrition Critical Element Pathway or the CMS State Operations Manual .

Final Thoughts
Managing food allergies in healthcare settings ensures patient/resident safety and
quality of care. By recognizing the Big 9 allergens and maintaining rigorous standards,
healthcare providers can create an environment where every patient and resident feels
cared for and protected.