When Matt Mitchell was four years old, his parents took him out one night to McDonald’s for a hamburger. But when he bit into it, he tasted cheese. For most people, getting the wrong order is, at worst, a nuisance. But as far as restaurant patrons go, Mitchell isn’t most people. Not long after taking that first bite, his body rebelled.

“I started vomiting, I was covered in hives, it was difficult to breathe,” Mitchell, now 20, says.

He was going through anaphylaxis, an extreme, often life-threatening reaction to an allergen. Mitchell is allergic to dairy, one of eight common ingredients that account for 90 percent of all food allergic reactions. (The others are egg, peanut, tree nuts, fish, shellfish, wheat, and soy.) While he did not go to the hospital that night—“probably not a very wise idea in hindsight,” he says—he had to take medicine to avert dire consequences.

Mitchell is one of millions of Americans with food allergies, which are becoming more prevalent and severe nationwide, according to the Food Allergy and Anaphylaxis Network (FAAN).

While the exact number of those with food allergies was recently questioned in a University of California study by Dr. Marc Riedl (he estimates only about 8 percent of children and less than 5 percent of adults), the challenges these diners pose for restaurants is undoubtedly mounting. In a 2007 study, FAAN found that of the 63 food allergy–related fatalities between 1996 and 2006, half involved restaurants. That statistic, advocates for the food-allergy community say, suggests a lack of awareness in the restaurant industry.

“I’ve gone into restaurants where, based on the dialogue I had with them, I could tell that they really didn’t understand enough to be able to serve us safely, and I’ve had to get up and walk out,” says Lynda Mitchell, Matt’s mother and president of the nonprofit Kids With Food Allergies.

Many restaurants don’t understand the basics of serving customers with food allergies, advocates say. A common mistake is confusing an allergy with an intolerance, which is typically the less severe of the two dietary restrictions.

“I can’t tell you how many times I’ve had to explain the difference between a lactose intolerance and a milk allergy,” Matt Mitchell says. “And the difference is significant.”

Restaurants also don’t often realize that allergy contamination can’t be easily undone. Removing the slice of cheese from a Big Mac, for example, would not make it safe to eat for someone with a dairy allergy.

“It’s molecules that can kill,” says acclaimed chef and restaurateur Ming Tsai, a FAAN spokesman whose son has food allergies. “It doesn’t have to be a handful of peanuts.”

The lack of awareness in the industry prompted Massachusetts to pass a bill last year requiring restaurants to display a food-allergy awareness poster in staff areas, place labels on menus reminding customers to alert servers to any food allergies, and train “food protection managers” on food-allergy issues. The new law, which is scheduled to take effect next month, also allows qualifying restaurants to earn a “Food Allergy Friendly” designation from the Department of Public Health.

FAAN calls the bill “landmark legislation” in the fight to make restaurants safer for people with food allergies. Chris Weiss, FAAN’s vice president of advocacy and government relations, says he expects Massachusetts to serve as an example for the rest of the country.

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“We’re pretty optimistic that other states will follow suit starting next year,” Weiss says. “Once it’s fully implemented in all the restaurants, we really hope other states will see what they’ve done up in Massachusetts and say, ‘Hey, let’s do that in our state.’”

There are already favorable signs. Weiss says a New York assemblywoman who was interested in adopting the bill in her state contacted him in February. Hawaii, New Hampshire, and Minnesota have also recently been “proactive when it comes to food-allergy issues,” Weiss says, leading him to expect legislative progress in the near future.

“I would like to see the Massachusetts legislation replicated in at least 10 states in the next five years,” he says. “And I think that’s doable.”

Doable, perhaps, but certainly not easy. The Massachusetts bill took five years to pass, in part because of disagreements between FAAN and the state restaurant association over its language, which was originally “very strong,” Weiss says.

One FAAN proposal that didn’t make it into the final bill was to require restaurants to create a master ingredient list so customers with food allergies would be able to know exactly what was in each dish. The Massachusetts Restaurant Association (MRA) thought the requirement too onerous.

“It was a major source of disagreement,” says MRA spokeswoman Janine Harrod.

Harrod says the association was concerned that some restaurants would either not be able to accurately create the list or not always be able to stick to it.

“Are you really helping a customer with food allergies if you’re making a guarantee you can’t live up to?” she says.

The question goes to the heart of a debate over how far restaurants should have to go to accommodate anyone who comes through its front doors. As the dispute over the master ingredient list suggests, there is disagreement on this issue between food-allergy advocates and the restaurant industry. Both, however, tend to agree that restaurants need to be more aware, even if that means being aware of their own ignorance.

“I think restaurants have a responsibility to be 100 percent honest with their customers,” Harrod says. If they aren’t confident they can serve people with food allergies, “they should divulge that to their customers, because that’s in everyone’s best interest.”

But Tsai, whose Blue Ginger in Boston ranks among the nation’s most allergy-friendly eateries, doesn’t think the “know what you don’t know” standard is sufficient. A staunch advocate for increasing awareness about food allergies in the restaurant industry who also worked on the Massachusetts bill, Tsai says restaurants should have to know how to serve all customers, dietary restrictions notwithstanding.

“It shouldn’t be a choice,” he says. “You can choose not to be in the business if you don’t know what’s in your food. Period.”

Tsai’s passion no doubt stems in part from seeing how the lack of awareness in the industry has affected his own child. He recalls a time when a restaurant operator told him, in front of his son, that the restaurant could not accommodate customers with food allergies and suggested they dine elsewhere.

While many parents of children with food allergies say they appreciate being told upfront that a restaurant isn’t allergy friendly, Tsai was outraged.

“If my son wasn’t there, I would have decked him,” he says.

His reaction may sound extreme, but Tsai says his son left the restaurant asking, “What’s wrong with me?” Years later, he maintains that restaurant owners have a duty—not a choice—to serve whoever enters the store a safe meal.

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“I just can’t think of anything more un-American than ‘we can’t serve you,’” he says.

As a hardliner, Tsai practices what he preaches. In his restaurant, he has developed a system requiring any order by customers with food allergies to go through as many as six checks. It may sound complicated, and Tsai says “I’d be lying if I said it doesn’t slow us down on a busy Saturday night.” But he insists that the system, which is based on a food-allergy “cheat sheet” dubbed “the Bible,” is not excessively burdensome.

“It may sound difficult, but once you write it down, it’s black and white,” he says.

Tsai doesn’t represent the industry norm, and many don’t share his belief that restaurants can become allergy-friendly with relative ease. Some, Harrod says, would find the transition “difficult or maybe impossible.”

“Not every restaurant is as sophisticated and as in tune with these issues as Blue Ginger,” she says. “Obviously, Tsai has set the gold standard for the rest of the industry, and we want everyone to get there. But at this point, we just don’t think it’s realistic.”

But it’s not just fine-dining restaurants that have found ways to serve customers with dietary restrictions. Chipotle is a favorite among people with food allergies or celiac disease (a hypersensitivity to gluten in the small intestine). Lynda Mitchell says her son eats there “three times a week when he’s home.” And the Denver-based chain hasn’t had to bend over backward to earn its reputation.

“There are essentially two things that we do that serve us well in this area,” says spokesman Chris Arnold. “We use whole, unprocessed ingredients and … we don’t have standard menu items.”

Both help customers make sure they don’t eat anything that can send them to the hospital.

“There really isn’t any great magic to it,” Arnold says. “It’s pretty much that simple.”

P.F. Chang’s is also an industry leader when it comes to serving customers with food allergies or celiac disease. The Phoenix-based chain uses separate plates and cookware for people with dietary restrictions to avoid cross-contamination, and it has a computer program that can filter its menu of whatever allergies a customer might have and provide a printout of available options.

“P.F. Chang’s bows down to people” with food restrictions, says Alison St. Sure, whose Sure Foods Living Web site aims to increase awareness about food allergies and celiac disease.

Doing so, however, requires a lot of energy, resources, and knowledge, says P.F. Chang’s head chef Gregg Piazzi. For one thing, allergens and other potentially harmful ingredients aren’t always easy to spot.

“So many ingredients have so many different names,” Piazzi says. “Wheat has a thousand different names. Gluten has a thousand different names.”

Other challenges include cost—“I think the smaller restaurants could be hampered,” Piazzi says—and menu complexity.

“If you’re serving hamburgers and fries and that’s pretty much it, it would be pretty easy to make it happen,” he says. “For the Cheesecake Factory concepts of the world, who use so many items, it could be very difficult.”

Despite the challenges, there are several reasons restaurants may want to accommodate customers with dietary limitations, simple appreciation being one. While most people dine out to relax and avoid having to cook for themselves, these customers find that going out to eat is often very stressful. This is why they are so grateful when they do find a restaurant that can serve them tasty, non-life-threatening fare—the epitome of comfort food.

“It’s heartwarming,” Piazzi says. “I get standing ovations and I’m not even the one responsible.”

Of course, there is another, more material, benefit to running an allergy- or celiac-friendly restaurant: customer loyalty. With relatively few establishments catering to customers with dietary restrictions, those that do can expect to draw steady business from an underserved market—comprised of not just the 12 million Americans with food allergies, but their family members as well.

“The allergy kid determines where the family is going to eat,” says St. Sure, whose daughter is allergic or intolerant to at least seven common ingredients. “So restaurants aren’t just serving that one customer. They’re getting four loyal customers.”

The industry needs to recognize that “there’s business to be had,” St. Sure says. “Restaurants are underestimating how important it is for families to feel safe.”

The exception that proves the rule, P.F. Chang’s has profited from its status as a safe haven for the allergic and intolerant. In the three weeks after rolling out a gluten-free menu in February, the chain saw a 140 percent jump in sales of gluten-free items year over year in participating locations.

“I’m happy we’re ahead of the curve on this one,” Piazzi says. “It is really a captive audience right now.”

Along with increasing business, going allergy-friendly could, in the long run, cut costs by lowering insurance rates, Tsai says.

“That’s one of my hopes for the Massachusetts legislation,” he says. “If you become designated an allergy-friendly restaurant, hopefully insurance companies are going to say, ‘Hey, they’ve actually reduced their liability. They’re not going to risk cross-contamination and getting someone sick, or worse, killing someone. Let’s lower their insurance.’”

Tsai says this is what happened after more restaurants became certified through the Training for Intervention Procedures (tips) program designed to prevent drunk driving and other alcohol-related liabilities.

Then, too, the industry was reluctant to adapt, he says.

“No one likes change, but now everyone looks at TIPS training as a godsend,” Tsai says.

Change appears to be coming again to the restaurant industry. With the Massachusetts legislation set to take effect next month, other states may indeed decide to follow suit and enact their own allergy-awareness bill.

“This will be national within three to five years,” Tsai says with confidence.