Do food intolerances developed over time?

Yes, the food intolerance can be developed over time and this is because we became unable to digest some foods. The inability to digest foods is related to a reduced enzymatic activity or a sensitivity to a different food or chemicals. For celiac disease, which is an autoimmune condition, the genetic predisposition plays an important role, where consumption of gluten may trigger activation of autoimmune system and production of antibodies which subsequently cause inflammatory changes of the intestinal lining.

Common triggers for food intolerances are milk, gluten, artificial food colourings, preservatives, emulsifiers, artificial sweeteners and flavour enhancers, sulphites, salicylate, monosodium glutamate (MSG), caffeine, fructose, histamine (found in Quorn, mushrooms, pickled and cured foods, and alcoholic drinks).

Do food intolerances cause impact on gut?

Food intolerances may have a negative impact on gastrointestinal health. The prolonged ingestion of a non-tolerated food may cause alteration of the gut flora and inflammation of the lining of the small intestine. This condition can keep you from absorbing the nutrients, leading to nutritional deficiencies.

What are the symptoms of food intolerance?

The common symptoms are intestinal discomfort, bloating, gas, diarrhoea, migraine, and headache. When we talk about food intolerances, the amount of food ingested can determine the severity of the symptoms, which may appear few hours after the consumption and last for several hours or days.

What are the differences between food intolerances and allergies?

The mechanism involved in the intolerance and allergy reaction is different. In the allergy reaction there is an involvement of the immune system which recognises a food as allergen creating a possible danger. Consequently, the immune system produces chemicals which could cause different symptoms: breathing problems, throat tightness, hoarseness, coughing, vomiting, abdominal pain, hives, swelling, drop in blood pressure and even life-threatening reaction like anaphylactic shock. Food intolerances like lactose and gluten intolerance do not involve this type of immune system responses.

Is Singaporean cuisine safe for people with common allergies such as nuts, soy, shellfish, lactose, gluten, and eggs?

Singaporean cuisine may be difficult for people with food allergies. Due to the mix of different cultures, many common allergens are found in number of dishes and delicacies in Singapore. Additionally, due to lack of awareness, high-risk situations, where cross-contamination can be present are frequent, especially at barbeques, buffets, self-service salad bars, deli counters and food courts. However, there are still variety and options that could be used and here are some advices you might find helpful.

What local dishes should people with common allergies avoid? Are there any alternatives?

Nuts and seeds

You can find them in many preparations, for example in sauces: spicy mix of different Malay dish, in the chilli paste of Chinese noodle or in satay sauce. They can be used as a filling for preparations like sesame or beans filling in tang yuan. They are added as a topping like rojak, or as ingredient like in mee chiang kueh pancakes, kueh tutu steamed cake or nasi lemak. Peanut oil and roasted sesame oil are commonly used to fry food or added to congee and chicken rice for flavour. Lastly seeds are part of some Chinese, Japanese, and Malay desserts.

 Dish to be avoided if someone have nuts allergy: Chinese rojak, lotus soup, gado gado, nasi lemak, setay sauce, muah chee, fa sang wu.

 Safe alternatives: beef noodles, mee soto, pork soup, roti prata, murtarabak, coconut base desserts.

Soy

Soy is a staple food in Asia and the most commonly used ingredient is the soy sauce present in chicken rice, fried vermicelli or bee hoon, fried flat rice noodles, some types of chilli dip and as ingredients in savory cakes. Fried tofu, bean curd skin, fermented beans like natto or tempeh are added to different preparations or used as ingredients for a soup stock. Soyabean oil is used for fried dishes.

 Dish to be avoided in people with soy allergy: char kuay teow, dark carrot cake, mee siam, kecap manis, sayur lodeh, yong tau hu stock, ngoh hiang, vegetarian bee hoon.

 Safe alternatives: Indian or western foods.

Fish and shellfish

Some sauce may contain them like shrimp paste sauce, sambal chilli sauce and fish sauce. Different foods are made with these sauces like carrots cake or spice mixtures in Malay dishes, cincalok (fermented shrimp paste and rice mixture).

Ikan bilis or fried anchovies and shrimp roe can be sprinkled on top of soups or preparations and used to prepare the stock (yong tau hu soup stock is made with anchovies and Hong Kong-style wanton noodles may include shrimp roe).

 Dish to be avoided in people with fish allergy: carrot cake, cincalok, Hong Kong-style wanton noodles, Hokkien prawn mee, yong tau hu soup, fish ball noodle soup/dry, laksa, mee goreng, nasi lemak.

 Safe alternatives: Cantonese roast meats on rice, chicken rice, popiah (without prawns), chwee kway.

Milk and lactose

Ghee, yogurt, paneer, and milk are quite common in Indian preparations and milk is also added to some fish soup sometimes.

 Dish to be avoid in people with milk allergy: Indian murtarabak, roti prata, Biryani rice, chicken masala, chicken butter, chicken tandoori, chicken and fish tikka.

 Safe alternatives: Asian dishes are relatively safe unless cross contamination. Sauces may contain milk and dairy, please ask sauces as a side.

Gluten

Wheat is another staple food that can be found anywhere. It is the main ingredient for wheat noodle, dumpling, pies, bread, puffs, flatbread, bun and tarts. Wheat flour can be used to coat fish or meat and it is sometimes used to thicken gravies. It can be found in foods that contain soy or fish sauce and processed meat and fish.

 Dish to be avoided in people with gluten intolerance: Wheat noodles dishes, ban mian soup, fish bee hoon soup, hokkien prawn mee, vegetarian bee hoon, wontong mee, gado gado, mee goreng.

 Safe alternatives: Rice, rice noodles and rice dumplings dishes, chicken rice, char siew rice pork, duck rice, fried rice, setay, nasi biryani, chicken tandoori, chicken or fish tikka.

Eggs

Some type of wheat noodles may contain eggs like wonton noodles, lo mein and chow mein noodles, mee pok noodles, dumpling skins. Bakery products like pies, bread, puffs, custard buns and tarts. Some fish soup may contain some deep-fried egg floss. Fried foods usually have eggs when battered, some type of tofu, carrot cake, crepes, and fried rice.

 Dish to be avoided in people with egg allergy: fried carrots cake, fried rice and Indian murtarabak, nasi lemak, nasi goreng, mee siam, mee goreng.

 Safe alternatives: chicken rice, Cantonese roast meats, satay.

Can people grow out of food allergies?

Different studies showed that a high percentage of kids, around 90%, outgrow dairy, egg, wheat, and soy allergies, but the chances that a shellfish, tree nut, or peanut allergy fade away are much lower. Food intolerances can improve when an exclusion diet is followed for a limited period. The incriminated food is then added in small amount to determine the maximum quantity that can be tolerated. This is not possible for celiac disease, where a gluten free diet must be followed for life.

The diet has a crucial role in modulating intestinal inflammation and the risk of inflammatory bowel disease, so the avoidance and/or reduction of proinflammatory foods is considered a good practice for disease prevention.

The CDED is a diet which exclude or limit exposure to foods that may negatively affect the microbiome or alter intestinal barrier function. The CDED is divided into three phases and they all include Partial Enteral Nutrition (PEN) from formula and mandatory foods to ensure high quality nutrition and changes in the bacteria of the gut: high quality lean protein, resistant starch and fibre. The diet includes a list of foods that need to be avoid to prevent inflammatory process.

FOODS TO AVOID/LIMITS

PHASE 1 AND 2

Phase 1 is weeks 0-6

• Complete nutrition formula/shake should constitute 50% of total energy intake
• 5 mandatory foods
• List of allowed foods

Phase 2 is weeks 7-12

• Complete nutrition formula/shake should constitute 25% of total energy intake
• 5 mandatory foods
• Expanded list of foods
• Additional fruits and vegetables allowed for weeks 7-9 and others allowed starting week 10

PHASE 3

Maintenance

• Complete nutrition formula/shake should constitute 25% of total energy intake
• There are no mandatory foods, however, potentially harmful foods should continue to be limited or avoided
• Goal is to maintain phase 2 diet with additional foods 5 days per week
• Allowed 2 homemade “free” meals 2 days per week (some allowance for restaurant meals)
• There are few foods not allowed at all

Food groups	Mode of introduction
Protein	Fresh chicken breast 5 oz or more (mandatory food) included in all phases of the diet, other chicken parts except wings, skin, and internal organs allowed in stage 3. Eggs 2 per day (mandatory food) included in all phases of the diet. Fresh fish 1 serving once weekly to substitute for serving of chicken included in all phases of the diet. Tuna canned in olive or canola oil twice weekly allowed in phase 2 and 3. Fresh seafood or salmon 1 serving allowed once weekly in phase 3. Lean beef steak (such as sirloin) 6 oz once weekly. Allowed in phase 2 and 3, however, recommended to avoid if possible. Almonds or walnuts, unprocessed, unroasted, unsalted, 6-8 per day allowed in phase 2 and 3. Raw tahini, free from preservatives and sulfites, 2 tablespoons per day allowed in phase 2 and 3.
Dairy	Yogurt, natural, unprocessed, full fat, without additives, 1 serving allowed daily in phase 3.
Legumes/beans	Lentils, beans, peas, chickpeas, dried, 1⁄2 cup (uncooked), not frozen or canned allowed in phase 2 and 3.
Fats/oils	Olive oi, avocado oil and canola oil allowed in all phases.
Fruits	Banana, 2 daily (mandatory) allowed in all phase. Apple, 1 peeled (for first 6 weeks) and cooked daily (mandatory) allowed in all phases. Avocado, 1 per day (1/2 per meal) allowed in all phases.Strawberries, 5 per day allowed in all phases.Melon (cantaloupe or honey dew), 1 slice allowed in all phases. Orange juice, freshly squeezed 1 glass per day allowed in all phases. Pear, kiwi, and peach, allowed in phase 2 and 3. Blueberries, 10 as a substitute to strawberries allowed in phase 2 and 3. Mango, pineapple, oranges, 1⁄2 cup cubes allowed after week 10. Other fruits allowed in phase 3 except pomegranate, permission, cactus, and passion fruit.
Vegetables	Potatoes, 2 peeled (for the first 6 weeks), cooked, and refrigerated per day (mandatory) allowed in all phases. Tomatoes, 2 allowed daily in all phases. Carrots, 2 peeled allowed in all phases. Spinach, fresh, uncooked 1 cup allowed in all phases.Lettuce, 3 leaves allowed in all phases. Sweet potato or yam, 1⁄2 substitute for potato allowed in phase 2 and 3. Zucchini (1 large or 2 small), 4-6 mushrooms, 2 flowerets of broccoli or cauliflower (not at the same time) are allowed in phase 2 and 3. Other vegetables allowed after week 10 except kale, leeks, asparagus, and artichoke.
Starches/grains	Rice, unlimited, including rice flour and rice noodles allowed in all phases.Quinoa, unlimited allowed in phase 2 and 3.Oatmeal, 1⁄2 cup allowed in phase 2 and 3.Bread, homemade made with baking powder instead of yeast, 1 slice per day allowed in phase 2 and 2 slices allowed in phase 3.Pasta, 1 cup cooked as a substitute for bread allowed in phase 3.
Other	Pure spices allowed in all phases.Fresh herbs allowed in all phases.Water and sparkling water allowed in all phases.Herbal teas.Honey, 3 tablespoons per day allowed in all phases.Table sugar, 4 teaspoons per day allowed in all phases.Onions, garlic, ginger, and fresh lemon juice allowed in all phases.Baking soda and baking powder allowed in phase 2 and 3.

Bibliography

1. Arie Levine et al. Crohn’s Disease Exclusion Diet Plus Partial Enteral Nutrition Induces Sustained Remission in a Randomized Controlled Trial. Gastroenterology. 2019 Aug;157(2):440-450.e8. doi: 10.1053/j.gastro.2019.04.021. Epub 2019 Jun 4. PMID: 31170412 DOI: 10.1053/j.gastro.2019.04.021
2. Rotem Sigall Boneh et al. Dietary Therapy With the Crohn’s Disease Exclusion Diet is a Successful Strategy for Induction of Remission in Children and Adults Failing Biological Therapy. J Crohns Colitis. 2017 Oct 1;11(10):1205-1212. doi: 10.1093/ecco-jcc/jjx071. PMID: 28525622 DOI: 10.1093/ecco-jcc/jjx071.
3. Jennifer Smith, MS, RD, CSP, LD, LMT. Introduction to Crohn’s Disease Exclusion Diet. ANHI Abbot Nutrition Health Institute.
4. Chun-Han Lo et al. Dietary Inflammatory Potential and Risk of Crohn’s Disease and Ulcerative Colitis. CLINICAL—ALIMENTARY TRACT| VOLUME 159, ISSUE 3, P873-883.E1, SEPTEMBER 01, 2020. Published:May 07,2020DOI: https://doi.org/10.1053/j.gastro.2020.05.011

Carbohydrates

Food allowed	Food not allowed/ to reduce	Tips/other info
- White or brown bread, sourdough bread, English muffin, bagels, pitta bread, plain naan bread, plain chapatti, white or wholegrain flour. - Breakfast cereals such as: Corn Flakes, Rice Krispies, Special K, rice porridge, All-Bran, Weetabix, muesli, oat porridge. - White rice, basmati or jasmine rice, pasta and noodles, sweet potatoes and potatoes, plain crackers or breadstick, cous cous, semolina, polenta, quinoa, buckwheat, wholegrain rice and noodles.		- Some patients may have problems with the wholegrains products, corn or bakery products containing dried fruit or nuts, so please try to use them in moderation or avoid them if they are triggering any symptoms.

Vegetables

Food allowed	Food not allowed/ to reduce	Tips/other info
- Cooked or raw vegetables.	- Tomato and tomato based products, spring onion, onion, garlic, chili, curry, pepper and mint. - Vegetables with fatty sauces, cream, cheese, bacon or lard. - Pickled or fermented vegetables like kimchi or sourkrauts and others prepared in oil or brine.	- Small amount of those foods can be tolerated, but generally they need to be avoided because they increase the acid production. - Mint and spices reduce the tone of the lower esophageal sphincter increasing the gastric reflux. - Sometimes raw vegetables, can be difficult to be digested, so please try to alternate them with the cooked one.

Fruits

Food allowed	Food not allowed/ to reduce	Tips/other info
- Cooked or raw fruit.	- Citrus and citrus juices.	- Sometimes raw fruit or dried fruit, nuts or seeds can be difficult to be digested, so please try to use them in moderation if they are triggering any symptoms. Alternatively, you can use cooked fruit and use smooth peanut butter, nuts butter or seeds butter instead.

Milk and dairy products

Food allowed	Food not allowed/ to reduce	Tips/other info
- Pasteurized milk, cheese, yoghurt and Greek yogurt. - Vegetable alternatives like almond, oat and rice milk.	- Coconut milk.	- Sometimes full fat milk and dairy are not well tolerated. In case they are triggering any symptoms, please choose low fat alternatives.

Meat and alternatives

Food allowed	Food not allowed/ to reduce	Tips/other info
- All meats, poultry (choose leaner cuts like sirloin, round and loin), fish, eggs and legumes (beans, lentils, chickpeas, peas, etc..).	- Tough meats with fat and smoked or cured deli meats, stews, goulash, boiled meat, ragout. Skin of the chicken, fatty meat, processed meat or fish (like meat balls, salami, fish balls, etc..). Organs, kidney, brain and liver.	- Cook the meats without adding sauces or other fatty gravies. - Remove all the visible fat before cooking, especially the skin of the chicken and fish. - Sometimes legumes can give bloating and gas, if so, please reduce their consumption or soak them for long time before cooking.

Snack, Sweets, Condiments and Beverages

Food allowed	Food not allowed/ to reduce	Tips/other info
- Water (1,5-2 liters/day), including herbal tea, light barley coffee, chamomile, fresh vegetables/fruit juices, coconut water. - Salt, herbs (like oregano, sage, thyme, basil leaves, rosemary, coriander, etc..), ginger. - Oils (olive oil, avocado oil are good options).	- Alcohol, carbonated beverages, soft drinks, coffee, black tea, citrus juices. - Chocolate, chewing gum, candy sweets in general, fatty food like: fried food, coconut milk or cream, sauces, sauces with cream, oily foods, margarine, butter, lard, desserts with creams, broth high in fat.	- Chewing gum and candy can worsen the symptoms because the sucrose contained, fermenting, increases the production of air in the stomach, and prolonged chewing stimulate the production of acids. - Fats, heavy condiments and sauces need to be avoid because they can slowing down gastric emptying, increasing the symptoms. - Use low-fat cooking methods like boil, bake, grill, steam and stir-fry (max few times per week). - Usually Chamomile, Melissa and Valerian herb tea can help in reducing the discomfort.

How does my plate look like?

Portion size

Half plate of vegetables

• Take 1 portion of vegetables in every main meal.
• Take 1 portion of fruit for breakfast, as a snack during middle morning and/or afternoon. Prefer the whole fruit instead of fruit juices.

A quarter plate of grains

• Depending on your age and gender, take 4-6 portions a day.

A quarter plate of protein (to use 3 times a day) to choose among:

Eggs

• Use not more than 2-3 egg yolks per week. If you want to exceed the consumption, you can take egg white.
• Portion size: 2 eggs or 1 egg + 1 white.

Poultry and meat

• Limit red meat like beef, pork, mutton, duck to 1-3 times a week. Prefer chicken and turkey.

Fish and seafood

• Consume fish 3-4 times per week.

Dairy Products

• Use 1-2 portions of milk or yogurt per day (preferably during breakfast or snacks).
• Use 1-3 portions of cheese per week. For the hard cheese you have the portion above, for the soft cheese or low fat cheese you can double the portion.

Legumes

• You can choose 2-3 times a week lentils, chickpeas, peas or beans or other legumes.
• Please reduce to few times per week the consumption of soya beans and soya products like tofu, edamame, soya milk, tempeh, etc..

Healthy fat

• Use one portion of nuts or nuts spread during breakfast or as a snack.
• Use 3-4 tablespoons of good oils per day.

Source pictures: www.healthhub.sg; www.eatrightontario.ca

What Is a Low-Residue Diet?

It’s a diet that limits high-fiber foods, such as whole-grain breads and cereals, nuts, seeds, raw or dried fruits, and vegetables.

“Residue” refers to undigested food, including fiber, that make up stool. The goal of the diet is to have fewer, smaller bowel movements each day, in order to ease symptoms such as diarrhea, bloating, gas, and stomach cramping.

Carbohydrates

Food allowed	Food not allowed/ to reduce	Tips/other info
- White bread, white sourdough bread, English muffins, plain scones and bagels, pancakes, white pitta bread, plain naan bread, plain chapatti, white flour. - Refined breakfast cereals such as: Corn Flakes, Rice Krispies, Special K, rice porridge. - White rice, pasta and noodles, sweet potatoes and potatoes (no skin), plain crackers or breadstick. - Plain biscuits no seeds, plain sponge cake made with white flour.	- Wholemeal, rye bread, all fruit/nut breads, including walnut, granary or fruit muffins or scones and pastries with fruit/dried fruit. - Wholegrain cereals such as: All-Bran, Weetabix, muesli, oat porridge. - Brown rice, brown pasta, cous cous, semolina, polenta, quinoa, buckwheat, pearl barley, teff, millet, wheat germ, wholemeal noodles, popcorn. - Biscuits or cakes made using: oats, dried fruit or dried coconut or nuts.

Vegetables

Food allowed	Food not allowed/ to reduce	Tips/other info
- Well-cooked fresh vegetables or canned vegetables without seeds, such as asparagus tips, beets, carrots, squash, capsicum (no seeds and no skin), pumpkin, zucchini, eggplants, tomato sauce (no seeds), strained vegetable juices.	- Raw vegetables, broccoli, Brussels sprouts, cabbage, corn (and corn bread), onions, cauliflower.

Fruits

Food allowed	Food not allowed/ to reduce	Tips/other info
- Banana, soft cantaloupe, honeydew, papaya,  avocado, durian, canned or cooked fruits without seeds or skin, such as applesauce or canned pears, or stewed apple or pears, fresh squeezed no pulp orange juice and no pulp centrifugate. - Smooth peanut butter, nuts butter or seeds butter.	- All fruit skins, stalks, seeds and stones. - Raw or dried fruits, such as prunes, berries, raisins, figs, and pineapple, dried coconut,  smoothies with pulp. - Whole nuts, seeds, including pumpkin, sunflower and sesame seeds.

Milk and dairy products

Food allowed	Food not allowed/ to reduce	Tips/other info
- Milk, cream, sour cream, crème fraiche, hard cheese, soft cheese, smooth yoghurt, Greek yogurt, paneer.	- High-fat cheese like gorgonzola, brie, camembert, blue cheese, creams, milk solids, condensed milk or powder milk or cream, butter, ghee, margarine. - Coconut milk or cream. - Any milk products containing fruits, nuts, seeds or cereals.	- Be sure that all the dairy products are made from pasteurized milk. - Use lactose-free products and hard cheese if the consumption of normal milk and dairy increase your symptoms.

Meat and alternatives

Food allowed	Food not allowed/ to reduce	Tips/other info
- All meats, poultry, fish, eggs and plain/firm tofu.	- Tough meats with fat and smoked or cured deli meats, stews, goulash, boiled meat, ragout. Skin of the chicken and fish, fatty meat, processed meat or fish (like meat balls, salami, fish balls, etc..). Organs, kidney, brain and liver. - Quorn and legumes like beans, lentils, peas, baked beans, soya beans, edamame, tempeh, silken tofu chickpeas, etc…	- Cook the meats without adding sauces or other fatty gravies. - Remove all the visible fat before cooking, especially the skin of the chicken and fish.

Snack, Sweets, Condiments and Beverages

Food allowed	Food not allowed/ to reduce	Tips/other info
- Water (1,5-2 liters/day), including herbal tea, light barley coffee, chamomile, apple juice, herbal tea, carbonated beverages and coffee. Juices made without seeds or pulp, such as apple juice, no-pulp orange juice, and cranberry juice, strained vegetable juices. - Clear vegetable soup and broth without fat. - Smooth jam or marmalade, honey, maple syrup.	- Ice cream containing fruit and nuts, cakes, puddings and pies containing any of the following: wholemeal flour, dried fruit, nuts, dried coconut and any fruits you have been advised to avoid. - Soup with pieces, such as minestrone. - Jam or marmalade with skin, peel or pips, chocolate with dried fruit, nuts or seeds, coconut. - Wholegrain mustard, pickles, relish.	- Use low-fat cooking methods like boil, bake, grill, steam and stir-fry (max few times per week). - Caffeine can irritate the stomach, and give you intestinal discomfort, so do not exceed.

How does my plate look like?

Portion size

Half plate of vegetables

• Take 1 portion of vegetables in every main meal.
• Take 1 portion of fruit or fruit juices or for breakfast and as a snack during middle morning and/or afternoon.

A quarter plate of grains

• Depending on your age and gender, take 4-6 portions a day.

A quarter plate of protein (to use 3 times a day) to choose among:

Eggs

• Use  3-4 egg yolks per week. If you want to exceed the consumption, you can take egg white.
• Portion size: 2 eggs or 1 egg + 1 white.

Poultry and meat

• Limit red meat like beef, pork, mutton, duck to 1-3 times a week. Prefer chicken and turkey.

Fish and seafood

• Consume fish 3-4 times per week.

Dairy Products

• Use 1-2 portions of milk or yogurt per day (preferably during breakfast or snacks).
• Use not more than 1-3 portions of cheese per week. For the hard cheese you have the portion above, for the soft cheese or low fat cheese you can double the portion.

Legumes

• Legumes are not allowed in a low residual diet. You can try to have once a week firm or plain tofu and monitor your symptoms.
• Portion size 120 – 140 g.

Healthy fat

• Use one portion of spread during breakfast or as a snack.
• Use 3-4 tablespoons of good oils per day.

Source pictures: www.healthhub.sg; www.eatrightontario.ca

General advice

• Avoid large meals, preferring small and frequent meals (4-5 per day)
• Reduce or avoid the intake of foods rich in fats.
• Eat slowly and chew well your food.
• In case of overweight or obesity, it is advisable to gradually reduce weight and waist circumference through a balanced diet, associated with regular exercise.

Carbohydrates

Food allowed	Food not allowed/ to reduce	Tips/other info
- Plain chapatti of flat bread without yeast. - Breakfast cereals such as: Corn Flakes, Rice Krispies, Special K, rice porridge, All-Bran, Weetabix, muesli, oat porridge. - White rice, basmati or jasmine rice, pasta and noodles, sweet potatoes and potatoes, cous cous, semolina, polenta, quinoa, buckwheat, wholegrain rice and noodles.	- Bread crumbs, highly leavened industrial foods including toast bread. White or brown bread, sourdough bread, English muffin, bagels, pitta bread, naan bread, plain crackers or breadstick.	- Avoid foods that are made with a significant amount of yeast, like bread and all bakery products.

Vegetables  

Food allowed	Food not allowed/ to reduce	Tips/other info
- Cooked or raw vegetables.	- Some vegetable may increase uric acid levels: legumes (beans, lentils, peas, chickpeas), spinach and mushrooms. - Vegetables with fatty sauces, cream, cheese, bacon or lard.

Fruits

Food allowed	Food not allowed/ to reduce	Tips/other info
- Cooked or raw fruit. - Nuts, seeds, nuts spread.	- Avocado

Milk and dairy products

Food allowed	Food not allowed/ to reduce	Tips/other info
- Low-fat milk and dairy.	- Full cream milk and dairy products with high fats: whole cream milk, cream, sour cream, fatty cheese like brie, burrata, mozzarella bufala or other cheese with added cream, brie, camembert, etc...

Meat and alternatives

Food allowed	Food not allowed/ to reduce	Tips/other info
- Poultry (choose leaner cuts), fish, eggs.	- Red meat like beef, pork, bacon, lamb, mince meat, meatball. - Internal organs: kidney, liver, intestines, meat gravies, meat extracts, fish roe, tongue and brains among others. – Tough meats with fat and smoked or cured deli meats, stews, goulash, boiled meat, ragout. Skin of the chicken, fatty meat, processed meat or fish. - Broth made from red meat, like meat soup or dumpling filled with meat and broth. - Certain fishes to be avoided:  sardines, mussels, scallops, herring, mackerel, shrimps and anchovies, sushi, crabs and oysters. - Legumes (beans, lentils, red lentils, peas, chickpeas, soya beans).	- Cook the meats without adding sauces or other fatty gravies. - Remove all the visible fat before cooking, especially the skin of the chicken and fish.

Snack, Sweets, Condiments and Beverages

Food allowed	Food not allowed/ to reduce	Tips/other info
- Water (1,5-2 liters/day), including herbal tea, light barley coffee, chamomile, fresh vegetables/fruit juices, coconut water. - Salt, herbs (like oregano, sage, thyme, basil leaves, rosemary, coriander, etc..), ginger. - Oils (olive oil, avocado oil are good options) and olives.	- Alcohol especially beer, carbonated beverages, soft drinks, coffee, black tea, citrus juices. - Chocolate, cocoa, chewing gum, candy sweets in general, foods sweetened with sugar like sorbitol, mannitol, xylitol. - Fatty food like: fried food, coconut milk or cream, sauces, sauces with cream, oily foods, margarine, butter, lard, desserts with creams, broth high in fat.	- Use low-fat cooking methods like boil, bake, grill, steam and stir-fry (max few times per week). - Avoid foods that are made with a significant amount of yeast like beer or other fermented beverages.

How does my plate look like?

Portion size

Half plate of vegetables

• Take 1 portion of vegetables in every main meal
• Take 1 portion of fruit as a snack during middle morning and/or afternoon. Prefer the whole fruit instead of fruit juices.

A quarter plate of grains

• Depending on your age and gender, take 4-6 portions a day

A quarter plate of protein to choose among:

Eggs

• Use not more than 3-4 egg yolks per week. If you want to exceed the consumption, you can take egg white
• Portion size: 2 eggs or 1 egg + 1 white.

Poultry and meat

• Limit red meat like beef, pork, mutton, duck to 1-2 times per month. Prefer chicken and turkey.

Fish and seafood

• Consume fish 3-4 times per week.

Dairy Products

• Use 1 portion of low-fat milk or yogurt per day (preferably during breakfast or snacks)
• Use not more than 1-2 portions of low-fat cheese per week.

Legumes

• You can have lentils, red lentils, chickpeas, peas, firm or plain tofu 1-2 times per month after a long soaking and boiling.
• Portion size firm or plain tofu 120 – 140 g.

Healthy fat

• Use one portion of nuts, seeds or nuts spread for breakfast or as a snack.
• Use 3-4 tablespoons of good oils per day.

Source pictures: www.healthhub.sg; www.eatrightontario.ca

What Is a Low Histamine Diet?

It’s a diet that limits foods containing Histamine which is able to worsen the symptoms in people who suffer from allergic diseases. It is contained in a variety of foods and high concentrations of histamine are found mainly in the products which undergo to a fermentation process such as fermented cheeses, canned meats, wine, beer and even in fresh fish when it is not stored at the correct temperature.

As a result of this, the excess histamine goes into the blood inducing symptoms like:

• gastrointestinal disorders (diarrhea, abdominal pain, stomach pain, cramps or flatulence);
• headache and migraine attacks;
• rash, itching, hives;
• asthma, breathing difficulties;
• nausea, palpitations, vertigo;
• irritations of the nasal mucosa, such as a runny nose or a stuffy nose.

à It is important to reduce as much as possible the intake of food high in histamine or the food which may increase the release of histamine in the body:

• tomatoes, sauerkraut, spinach, potatoes, bell peppers and eggplants;
• canned food and sauces like Ketchup and soy sauce;
• canned fish: preserved, marinated, salted or dried (sardines, tuna, mackerel, anchovies, herring), smoked fish (herring, salmon ..);
• shellfish and seafood, egg white, pork meat;
• sausages, salami, dried meat, smoked ham and all the processed meat and fish (like fish balls, fishcake);
• hard cheeses, fermented cheese and cheese with mould, buttermilk, kefir, sourcream;
• fermented food like: fermented vegetables (sauerkraut and kimchi), pickles or pickled veggies, kombucha, tempeh, miso, soy sauce, and natto;
• spirits, wine, beer, wine vinegar;
• yeast (bread, pizza and bakery food);
• chocolate / cocoa;
• strawberry, banana, pineapple, papaya, citrus fruits (oranges, grapefruits …), kiwi, raspberry, pear, avocado;
• walnuts, hazelnuts, almonds and cashews;
• coffee, black tea, mate tea and green tea;
• food additives (in processed foods and drinks), such as colorants, preservatives, stabilizers, and flavorings.

àWhat should I eat?

• fresh or frozen meat and poultry choosing the lean cuts;
• fresh or frozen fish, such as cod, trout, snapper, grouper, dory, toman, or other white fish;
• fresh cheeses like ricotta, cottage cheese, mozzarella, milk, yogurt;
• vegetables milk like almond or coconut;
• fruit such as apples, peaches, apricots, melons, persimmons etc, except for the one mentioned above;
• fresh vegetables like broccoli, carrots, zucchini, pumpkin, asparagus, cauliflower, cucumbers and large leafy vegetables (lettuce, chicory …);
• gluten free grains like rice, rice noodles, quinoa, buckwheat;
• condiments: extra virgin olive oil or olive oil, salt and herbs.

General advice

• Avoid large meals, preferring small and frequent meals (4-5 per day). In this way you will digest better the food.
• Eat slowly and chew well your food.
• Avoid exercise immediately after food.
• Do not follow any fasting diet or intermittent fasting diet but eat regularly during the day. Please have complete meals with carbohydrates, protein and vegetables.

Carbohydrates

Food allowed	Food not allowed/ to reduce	Tips/other info
- White rice, basmati rice, rice noodles, pasta, sweet potatoes, potatoes, brown rice, wild rice, red rice, wholegrains, brown bread, quinoa, buckwheat, bulgur, teff, millet, oat. - Low-fat crackers, breadstick, and biscuits. Pitta bread, flatbread and bread. - Refined breakfast cereals such as corn flakes or puffed rice.	- Pasta or noodles with eggs as ingredients like fettuccini or tagliatelle or yellow noodles. - Bread with cheese or eggs as ingredients. - High-fat crackers, granola-type cereal, muesli, biscuits, pancakes, croissant, muffin cakes, rolls or cornbread.	- Choose a tomato-based sauce or vegetable sauce instead of cream-based or pesto or Bolognese or heavy sauces. - Granola and muesli are good options, but they contain nuts and seeds (good fats). You can take them sometimes, but do not add any other sources of fat in your breakfast or snack.

Vegetables

Food allowed	Food not allowed/ to reduce	Tips/other info
- All the vegetables you like. - Vegetables and fermented vegetables in brine.	- Vegetables prepared with added fat, cream sauces or cheese sauces. - Pickled vegetables and others prepared in oil; frozen vegetables in sauces; vegetables seasoned with bacon or lard or cheese.	- Alternate cooked with raw vegetables.

Fruits

Food allowed	Food not allowed/ to reduce	Tips/other info
- All the fruit you like including dried fruits and smoothies prepared with low fat/no fat dairy.	- Nuts, seeds and nuts butter or avocado and coconut.	- Nuts, seeds, nuts butter and avocado are healthy fruits, but they contain high amount of fat. If you exceed in their consumption you may have pain. Please if you want to use them, have a small portion, without any other fats in the same meal.

Milk and dairy products

Food allowed	Food not allowed/ to reduce	Tips/other info
- Milk, yogurt and cheese low fat or zero fat. Cottage cheese. Low fat creamy cheese and sour cream.	- Regular milk, butter milk, chocolate milk and cream. - Regular and processed cheese, hard cheese, mascarpone cheese, soft cheese.	- You can add low fat milk and yogurt during the cooking. You can also use zero fat/low fat yogurt to do sauces for your salad.

Meat and alternatives

Food allowed	Food not allowed/ to reduce	Tips/other info
- Skinless lean poultry (chicken or turkey). - Cooked ham or Parma ham (please remove the white fat.) Beef, pork or lamb (lean cut). - Eggs white. - All fresh or frozen lean white fish (snapper, grouper, dory, toman, cod, trout, etc..). Canned fish in water or brine. - Legumes (beans, butter beans, kidney beans, peas, lentils, chickpea, peas, soya).	- All fatty, oily and fried poultry. - Ribs, corned beef, sausage, duck or goose. Luncheon meats, fatty cold cut (salami, lard processed meat, etc..)  and meatball, offals, liver etc. - Egg yolk. - Salmon or fatty fish and seafood fresh or fried. Canned fish in oil, processed seafood and fish balls.	- Cook the meats without adding sauces or other fatty gravies. - Remove all the visible fat before cooking, especially the skin of the chicken and fish. - Salmon and fatty fish are healthy, but they contains high amount of fat. If you exceed in its consumption you may have pain. Please if you want to use it have a small portion, without any other fats or avocado or cream or cheese.

Snack, Sweets, Condiments and Beverages

Food allowed	Food not allowed/ to reduce	Tips/other info
- Fat-free broth or clear soups.– Fruits shake and sorbet (no added sugar). - Honey, jam, jellies, maple syrups. - Water (1,5-2 liters/day), including herbal tea, light barley coffee, chamomile, apple juice, coffee or black tea. - Salt and herbs, vinegar, lemon, lime juice, ginger, soya sauce, fish sauce, ketchup, mustard seeds and sauce (1 tsp), spices, garlic and garlic powder, onion and onion powder. - Olive oil, avocado oil, olives (to use in moderation.	- Sweets and desserts, biscuits, chips, candies, milk chocolate, puddings, ice cream, custard cream, sugary drink. - Limit alcohol (spirits, wine, beer) soft drink such as coke and other sugary drinks, cocktails, energy drink, instant coffee and instant tea. - Avoid MSG and stock cubes. Avoid deep fried food, stir-fried food, and elaborated preparations with fat, coconut milk, butter or margarine. - Avoid food and condiments containing bacon fat, bacon bits, and salt pork. - Avoid sauce like oyster, mayonnaise or other fatty sauces.

How does my plate look like?

Portion size

Half plate of vegetables

• Take 1 portion of vegetables in every main meal
• Take 1 portion of fruit for breakfast or as a snack during middle morning and/or afternoon. Prefer the whole fruit instead of fruit juices.

A quarter plate of grains

• Depending on your age and gender, take 4-6 portions a day

A quarter plate of protein to choose among:

Eggs

• Use only white egg
• Portion size: 2 – 3 eggs white

Poultry and meat

• Limit red meat like beef, pork, mutton, duck to 1-3 times a week. Prefer chicken and turkey.
• You can use cooked ham or Parma ham few times per week (remove the white fat).

Fish and seafood

• Consume fish 3-4 times per week

Dairy Products

• Use 1 portion of low-fat or zero-fat yogurt per day (preferably during breakfast or snacks)
• Use not more than 1-2 portions of low-fat cheese per week.

Legumes

• You can choose 2-3 times a week lentils, chickpeas, peas or beans or other legumes.
• Please reduce to few times every other week the consumption of soya beans and soya products like tofu, edamame, soya milk, tempeh, etc...

Healthy fat

• Use ½ portion of nuts or nuts spread occasionally based on your symptoms.
• Use 2-4 tablespoons of good oils per day.

Source pictures: www.healthhub.sg; www.eatrightontario.ca

General advice

• Avoid large meals, preferring small and frequent meals (4-5 per day)
• Do not have meals and snacks in 2-3 hours before bedtime
• Reduce or avoid the intake of foods rich in fats.
• Avoid too hot or too cold food and drinks.
• Avoid the intake of large amounts of liquids during meals, but sip them slowly throughout the day.
• Eat slowly and chew well your food.
• Avoid wearing very tight clothing or belt.
• If you suffer from night-time reflux is advisable to slightly raise the headboard of the bed and avoid snacks before bedtime.
• Avoid exercise immediately after food.
• In case of overweight or obesity, it is advisable to gradually reduce weight and waist circumference through a balanced diet, associated with regular exercise.

Carbohydrates

Food allowed	Food not allowed/ to reduce	Tips/other info
- White or brown bread, sourdough bread, English muffin, bagels, pitta bread, plain naan bread, plain chapatti, white or wholegrain flour. - Breakfast cereals such as: Corn Flakes, Rice Krispies, Special K, rice porridge, All- Bran, Weetabix, muesli, oat porridge. - White rice, basmati or jasmine rice, pasta and noodles, sweet potatoes and potatoes, plain crackers or breadstick, cous cous, semolina, polenta, quinoa, buckwheat, wholegrain rice and noodles.	-Bread crumbs, highly leavened industrial foods including toast bread.	- Some patients may have problems with the wholegrain products, white bread, corn or products containing dried fruit or nuts, so please try to use them in moderation or avoid them if they are triggering any symptoms. - Sometimes normal pasta, bread and noodles can give to patients feeling of fullness after meals, so in this case you may need to reduce the portion size.

Vegetables

Food allowed	Food not allowed/ to reduce	Tips/other info
- Cooked or raw vegetables.	- Tomato and tomato based products, turnips, cabbage, cauliflower, bean sprouts, Brussel sprouts, asparagus, broccoli, spring onion, onion, garlic, chili, curry, pepper and mint. - Vegetables with fatty sauces, cream, cheese, bacon or lard. - Pickled or fermented vegetables like kimchi or sourkrauts and others prepared in oil or brine.	- Small amount of those foods can be tolerated, but generally they need to be avoided because they increase the acid production. - Mint and spices reduce the tone of the lower esophageal sphincter increasing the gastric reflux. - Sometimes raw vegetables, can be difficult to be digested, so please try to alternate them with the cooked one.

Fruits

Food allowed	Food not allowed/ to reduce	Tips/other info
- Cooked or raw fruit. - Nuts, seeds, nuts spread.	- Citrus and citrus juices, grapes, mango, cherries, water melon.	- Sometimes raw fruit or dried fruit, nuts or seeds can be difficult to be digested, so please try to use them in moderation if they are triggering any symptoms. Alternatively, you can use cooked foods and use smooth peanut butter, nuts butter or seeds butter instead.

Milk and dairy products

Food allowed	Food not allowed/ to reduce	Tips/other info
- Lactose-free milk, yogurt and hard cheese. - Vegetable alternatives like almond, oat and rice milk.	- Coconut milk. - Normal full fat milk and dairy. - Whipped cream, milkshakes, smoothies and other foods rich in air.	- Sometimes even low fat and lactose-free milk and dairy can increase the symptoms, in this case avoid milk and dairy.

Meat and alternatives

Food allowed	Food not allowed/ to reduce	Tips/other info
- All meats, poultry (choose leaner cuts like sirloin, round and loin), fish, eggs.-Legumes (to use in moderation)	– Tough meats with fat and smoked or cured deli meats, stews, goulash, boiled meat, ragout. Skin of the chicken, fatty meat, processed meat or fish. Organs, kidney, brain and liver.	- Cook the meats without adding sauces or other fatty gravies. - Remove all the visible fat before cooking, especially the skin of the chicken and fish. - Legumes can give bloating and gas, if so, please avoid them, because this can increase stomach pain.

Snack, Sweets, Condiments and Beverages

Food allowed	Food not allowed/ to reduce	Tips/other info
- Water (1,5-2 liters/day), including herbal tea, light barley coffee, chamomile, fresh vegetables/fruit juices, coconut water. - Salt, herbs (like oregano, sage, thyme, basil leaves, rosemary, coriander, etc..), ginger. - Oils (olive oil, avocado oil are good options) to use in moderation.	- Alcohol, carbonated beverages, soft drinks, coffee, black tea, citrus juices. - Chocolate, chewing gum, candy sweets in general, foods sweetened with sugar like sorbitol, mannitol, xylitol. - Fatty food like: fried food, coconut milk or cream, sauces, sauces with cream, oily foods, margarine, butter, lard, desserts with creams, broth high in fat.	-Chewing gum and candy can worsen the symptoms because the sucrose contained, fermenting, increases the production of air in the stomach, and prolonged chewing stimulate the production of acids. - Fats, heavy condiments and sauces need to be avoid because they can slowing down gastric emptying, increasing the symptoms. - Use low fat cooking methods like boil, bake, grill, steam and stir-fry (max few times per week). - Usually Chamomile, Melissa and Valerian herb tea can help in reducing the discomfort.

How does my plate look like?

Half plate of vegetables

• Take 1 portion of vegetables in every main meal
• Take 1 portion of fruit as a snack during middle morning and/or afternoon. Prefer the whole fruit instead of fruit juices.

A quarter plate of grains

• Depending on your age and gender, take 4-6 portions a day

A quarter plate of protein to choose among:

Eggs

• Use not more than 3-4 egg yolks per week. If you want to exceed the consumption, you can take egg white
• Portion size: 2 eggs or 1 egg + 1 white.

Poultry and meat

• Limit red meat like beef, pork, mutton, duck to 1-3 times a week. Prefer chicken and turkey.

Fish and seafood

• Consume fish 3-4 times per week

Dairy Products

• Use 1 portion of low-fat and lactose free milk or yogurt per day (preferably during breakfast or snacks)
• Use not more than 1-3 portions of hard cheese per week. Please avoid soft cheese.

Legumes

• Please try to reduce the intake of legumes, especially if they give you intestinal discomfort or stomach pain.
• You can have lentils, red lentils, chickpeas, peas or beans or other legumes few times per week after a long soaking and boiling.
• You can try to have once a week firm or plain tofu (that usually is well tolerated) and monitor your symptoms. Portion size 120 – 140 g.

Healthy fat

• Use one portion of nuts, seeds or nuts spread for breakfast or as a snack.
• Use 3-4 tablespoons of good oils per day.

Source pictures: www.healthhub.sg; www.eatrightontario.ca

Colorectal cancer is the most common cancer in Singapore. The average population risk for developing colorectal cancer in Singapore is among the highest in the world. However this is a preventable cancer. Screening for colorectal cancer is proven to save lives. In the United States and northern European countries, colorectal cancer mortality has been falling, and this has been attributed to screening, early detection, prevention by polypectomy, and improved treatment.

Diet has long been thought to have a role in the etiology of colorectal cancer, particularly when a poor diet is combined with excess calorie intake and weight gain, physical inactivity, and unhealthy practices, such as smoking and consuming a great deal of alcohol. Since colorectal cancer, of all the major cancers, seems to have the closest links to diet, multiple studies have been looking into ways in which the cancer might be prevented through changing what and how much we eat.

DIET

Fruit, Vegetables, and Fibre: Fibre has been proposed to dilute or absorb fecal carcinogens and improve transit time in the colon. Clinical studies have shown that a high intake of vegetables or fibre was associated with an approximate 40 percent to 50 percent reduction in risk for colon cancer.

Red Meat, Fat, and Carbohydrates The results of US and European clinical studies found that consumption of red meat or processed meats more than five times a week _increased a risk of colon cancer three-times compared to those who consume red meat less than a month. Several studies have found that risk of colon cancer is specifically increased among meat eaters who consume meat with a heavily browned surface or meat that has been prepared at high temperatures at prolonged durations.

Calcium and Vitamin D Large clinical studies have consistently shown a significant inverse association between calcium intake and colorectal cancer risk. Vitamin D could reduce risk of colorectal cancer through various molecular and cell mechanisms, including its anti-inflammatory properties. It is important to achieve a level of vitamin D at least 30 ng/mL, since this dose has been shown to be optimal also for other health conditions.

B Vitamins B vitamins, particularly low dietary folate has also been specifically associated with increased risk of colorectal cancers. In 1998 USA introduced mandatory folate fortification of flour and breakfast cereals.

Antioxidants and Other Micronutrients Several other dietary micronutrients, including selenium, beta carotene, and vitamins A, C, and E are believed to have anti-carcinogenic effects, based on their anti-oxidant or anti-inflammatory properties. However the clinical studies showed that they do not appear to prevent colorectal cancer.

LIFESTYLE

Alcohol The relationship between alcohol and cancer has been controversial, but most evidence indicates that high intake of alcohol increases risk of colorectal cancer. Men who drink more than two glasses of alcohol per day had a two-fold higher risk of colon cancer compared to men who drank less than 0.25 glass per day.

Tobacco Studies in the U.S. have estimated that approximately 15 percent to 20 percent of colorectal cancers can be attributed to smoking. Tobacco use has been consistently associated with a two-fold increased risk of colorectal polyp-adenoma.

Body Mass and Fat Distribution Men in the highest quintile of BMI having nearly a two-fold higher risk of colon cancer compared with men in the lowest quintile. Women with a BMI >29 kg/m2 had a 1.5-fold increased risk of colon cancer and two-fold increased risk of large (≥ 1cm) adenoma. Fat distribution is also an important factor. Colon cancer risk increased with increasing waist circumference.

Physical Activity An association between greater levels of physical activity and decreased risk of colon cancer has been one of the most consistently observed. Physically active individuals had a 20 percent to 30 percent lower risk of colon cancer compared to less active individuals.

Prevention is better than cure. Cutting down intake of red and processed meats, high-fat dairy products, highly refined grains and starches, and sugars and replacing them with poultry, fish and plant sources as the primary source of protein can help reduce the risk. Improving the understanding of diet and healthy lifestyle might add further benefit and reduce risk of colorectal cancer.

CHOLECYSTECTOMY

General advice

• Avoid large meals, preferring small and frequent meals (4-5 per day). In this way you will digest better the food.
• Eat slowly and chew well your food.
• Avoid exercise immediately after food.
• Do not follow any fasting diet or intermittent fasting diet but eat regularly during the day. Please have complete meals with carbohydrates, protein and vegetables.
• Please follow the advice for at least 1 week after surgery, then slowly you can start to add slightly more fat and more variety of food.

Carbohydrates

Food allowed	Food not allowed/ to reduce	Tips/other info
- White rice, basmati rice, rice noodles, noodles, pasta, sweet potatoes, potatoes (no skin). - Low-fat crackers or breadstick, Pitta bread, Bread, Low-fat biscuits. - Refined breakfast cereals such as corn flakes or puffed rice.	- Pasta or noodles with eggs as ingredients like fettuccini or tagliatelle or yellow noodles. - Bread with cheese or eggs as ingredients. - High fat crackers, granola-type cereal, muesli, biscuits, pancakes, croissant, muffin cakes, rolls or cornbread. - Brown rice, wild rice, red rice, wholegrains, brown bread, quinoa, buckwheat, bulgur, teff, millet, oat.	- Choose a tomato-based sauce or vegetable sauce instead of cream-based or pesto or Bolognese or heavy sauces. - Avoid wholegrain products for one week because they are not easy to be digested after surgery.

Vegetables

Food allowed	Food not allowed/ to reduce	Tips/other info
- Fresh or frozen: zucchini, carrots, squash (no seeds), pumpkin, beets, eggplants, capsicum, tomato sauce or cooked tomato (no seeds and skin).	- Vegetables prepared with added fat, cream sauces or cheese sauces. - Sauerkraut, pickled vegetables, and others prepared in oil; frozen vegetables in sauces; vegetables seasoned with ham or bacon. - Raw vegetables, skins and pips of all vegetables. - All pulses such as beans, butter beans, kidney beans, peas, lentils, chickpea, peas, soya.	- Prefer cooked vegetables because easy to be digested. - The vegetables recommended are easy to be digested and you will not have any intestinal symptoms after consumption.

Fruits (2 portion per day or 3 small portion)

Food allowed	Food not allowed/ to reduce	Tips/other info
- Fresh, frozen and fresh fruit juices: banana, cantaloupe, honeydew, apple, applesauce, lemon and lemon juice, papaya, strawberry, pear, orange, orange juice.	- Nuts and seeds, peanut butter or nuts butter, dried fruits, avocado and coconut. - All fruit skins, stalks, seeds and stones.– Smoothies	- Use fruits as a snack: you can bake apple or pear with cinnamon and a bit of honey if you like. - The fruit recommended are easy to be digested and you will not have any intestinal symptoms after consumption.

Milk and dairy products

Food allowed	Food not allowed/ to reduce	Tips/other info
- Avoid till 1 week after the procedure.	- Milk, buttermilk, chocolate milk and cream. Regular and processed cheese, hard cheese, mascarpone cheese, soft cheese, low-fat creamy cheese and sour cream.	- Please don’t add milk, cream and yogurt during the cooking. - In the reintroduction phase, please use low-fat milk and dairy, cottage cheese, low-fat creamy cheese and sour cream.

Meat and alternatives (2-3 portions per day)

Food allowed	Food not allowed/ to reduce	Tips/other info
- Skinless lean poultry (chicken or turkey). - Meat only lean cut. Cooked ham and Parma ham (please remove the white fat). - Eggs white. - All fresh or frozen lean white fish (snapper, grouper, dory, toman, cod, trout, etc..).	- All fatty, oily and fried poultry. - Minced beef, pork or lamb. Ribs, corned beef, sausage, duck or goose. Luncheon meats, cold cut (salami, lard, bacon, processed meat, etc..)  and meatball, offals, liver etc. - Egg yolk. - Salmon or fatty fish and seafood fresh or fried. Canned fish in water, brine or oil, processed seafood and fish balls or fishcake. - Legumes (beans, lentils, chickpeas, peas, soya, etc..).	- Cook the meats without adding sauces or other fatty gravies. - Remove all the visible fat before cooking and the skin of the chicken or fish. - In the reintroduction phase, please use small amount of salmon or fatty fish and legumes. Continue to avoid processed fish like fishballs or fishcake.

Snack, Sweets, Condiments and Beverages

Food allowed	Food not allowed/ to reduce	Tips/other info
- Fat-free broth or clear soups. - Fruits shake and sorbet (no added sugar). - Honey, jam, jellies, maple syrups. - Water (1,5-2 liters/day), including herbal tea, light barley coffee, chamomile, apple juice. - Salt and herbs, vinegar, lemon and lime juice, ginger.	- Sweets and desserts, biscuits, chips, candies, milk chocolate, puddings, ice cream, cream, sugary drink. - Coffee, breakfast or black tea, sparkling water, alcohol (spirits, wine, beer, hidden alcohol in aperitifs or sweets or chocolate), soft drink such as coke and other sugary drinks, cocktails, energy drink, instant coffee and tea. - Avoid MSG and stock cubes. Avoid deep fried food, stir-fried food, and elaborated preparations with fat and coconut milk. - Avoid food and condiments containing bacon fat, bacon bits, and salt pork. - Avoid sauce like soya, fish, oyster, ketchup, mayonnaise or other fatty or salty sauces. - Avoid spices, hot pepper sauce, garlic and garlic powder, onion and onion powder. - Oil, olives, butter or margarine: at least for one week after the surgery.	You can replace oily sauces with the following: - lemon juice and parsley - orange and ginger - fresh tomato blended with basil leaves.

How does my plate look like?

Portion size

Half plate of vegetables

• Take 1 portion of vegetables in every main meal
• Take 1 portion of fruit for breakfast or as a snack during middle morning and/or afternoon. Prefer the whole fruit instead of fruit juices.

A quarter plate of grains

• Depending on your age and gender, take 4-6 portions a day

A quarter plate of protein to choose among:

Eggs

• Use only white egg
• Portion size: 2 – 3 eggs white

Poultry and meat

• Limit red meat like beef, pork, mutton, duck to 1-2 times a week. Prefer chicken and turkey.
• You can use cooked ham or Parma ham sometimes (remove the white fat).

Fish and seafood

• Consume fish 3-4 times per week

Dairy Products

• To reintroduce after one week from the surgery.
• Use 1-2 portions of low-fat milk or yogurt per day (preferably during breakfast or snacks)
• Use not more than 1-2 portions of low-fat cheese per week.

Legumes

• Please for at least 1 week avoid legumes consumption because they can give you intestinal discomfort.
• When you reintroduce them, please start with few times per week.

Healthy fat

• For at least one week please avoid any nuts or nuts spread.
• Reduce to the minimum the level of oils for at least 1 week after the surgery. If you are anable to cook without oils, you can use maximum 1-2 tablespoons of good oils per day.

Source pictures: www.healthhub.sg; www.eatrightontario.ca