Remember when you could enjoy a particular food in the past, but not so anymore without any stomach issues? That is the journey of ageing — apart from getting some wrinkles here and there, our digestion goes through changes as well. This change is known as food intolerance, an occurrence that can affect anyone at any age but increases as we get older. This is due to slower emptying of the stomach and microbial imbalance in the small intestine that come naturally with age.

Over 20% of the population in developed countries experience some form of food intolerance. A common one I see in Asian countries like Singapore is lactose intolerance, which comes with symptoms like diarrhea and abdominal cramps upon consuming dairy. In fact, about 65% of people do not digest lactose as well as soon as after infancy!

Allergy or intolerance?

Many people confuse food tolerances with food allergies because they share similar symptoms. However, both conditions are quite different, especially the impact of their onset.

A food allergy involves the immune system and occurs when the body mistakes a foreign ingredient —usually a protein— as harmful and attacks it by producing high levels of an antibody known as immunoglobulin E. What this means is that the patient goes through a slew of reactions, including:

• Rashes or hives
• Nausea
• Stomach pain or cramps
• Diarrhea
• Swelling
• Irregular heartbeat or difficulty breathing
• Anaphylactic reaction – the most severe life threating reaction

A food intolerance, on the other hand, stems from a digestive issue. As mentioned, food intolerances happen more often as you age as your digestion slows down, which allows more time for bacteria to ferment in your gastrointestinal tract. Apart from dairy, some common sensitivities I see are dried fruits, canned goods, and monosodium glutamate (MSG) found often in Chinese food and chips.

When triggered, food intolerance presents itself with symptoms like:

• Nausea
• Diarrhea
• Heartburn
• Stomach pain
• Headaches
• Irritability or nervousness

As you can see, the symptoms more or less mirror that of food allergies, except food intolerances are rarely ever life threatening.

Below, I have a simple summary of the difference between food allergies and food intolerances.

	FOOD ALLERGY	FOOD INTOLERANCE
What it affects & how it onsets	Affects the immune system, may affect multiple organs, may be life threatening, symptoms often appear quickly	Affects only the digestive system, less serious and symptoms take a while to onset
Who does it affect?	Usually diagnosed in childhood and carries through adulthood, although it may develop at any age depending on when the person is first exposed to the food	Usually developed in adulthood
What is it triggered by?	Usually triggered by specific food like fish, nuts, soy, milk, wheat, and eggs. Can be triggered even by a small amount	Usually triggered by multiple types of food groups like fructose, galactans, gluten, lactose, artificial sweeteners, and fermented food

Autoimmunity and food intolerance

We know that gluten can trigger celiac disease in genetically predisposed individuals, but are those with other autoimmune diseases more prone to food intolerance? Based on what we’ve studied so far, those with autoimmune diseases tend to have more food intolerances. Among the most reactive foods are wheat, cow milk, gliadin, casein, egg whites and rice. The good thing is that so far, we have not got many reactions from food like vegetables and fish (excluding shellfish) and meat.

How to manage food intolerance

A food tolerance can be tricky to pinpoint because you can still eat a small portion of a problem food without causing any trouble. What I make my patients do is to keep a detailed food diary and write down what they eat for every meal, including snacks and portion size. I get them to document the symptoms for every food.

Try to maintain this diary for 2 to 4 weeks and review it. You should be able to find a connection between symptoms, certain foods, and portion sizes. Once you pinpoint some food that coincides with your symptoms, try eliminating one ingredient at a time or adjust your serving sizes. This way, you can still enjoy your favorite food without experiencing symptoms.

For patients, whose problem food is a source of important nutrients, I make sure they find an adequate replacement. Take lactose intolerance for example. You can still get in plenty of calcium through lactose-free milk, almond milk, or other plant based milk fortified with calcium.

Overall, if managed well, food intolerance is nothing much to fret about and there are many ways to work around it without compromising on your quality of life!

References

1. Coucke F. (2018). Food intolerance in patients with manifest autoimmunity. Observational study. Autoimmunity reviews, 17(11), 1078–1080. https://doi.org/10.1016/j.autrev.2018.05.011
2. Di Costanzo, M., & Berni Canani, R. (2018). Lactose Intolerance: Common Misunderstandings. Annals of nutrition & metabolism, 73 Suppl 4, 30–37. https://doi.org/10.1159/000493669

At my clinic, we treat celiac disease, an autoimmune disorder that’s triggered by eating gluten. Gluten is a protein found commonly in wheat, rye and barley. If patients with celiac disease consume food with gluten, their immune system flares up by damaging the small intestine. By damage, it means experiencing digestive symptoms like diarrhoea, vomiting, abdominal pain and bloating.

People with one autoimmune disorder are more likely to get another autoimmune disorder. This is especially more so with celiac disease. In fact, compared to the general population, patients with celiac disease are at 15% more risk of developing one or more autoimmune disorders. The thing here also is that many people with celiac disease may even not know they have it. This is because the damage done to your intestine happens at a very slow rate, and sometimes symptoms are so generic and varied that it can take a few years to get a proper diagnosis. In some instances, about as many as 20% of people may be undiagnosed.

It’s important to note that celiac disease is not the same as gluten intolerance. While both conditions display a sensitivity towards gluten and exhibit similar symptoms, people with non-celiac gluten intolerance do not get damage to their small intestine or show any immune responses. I should also mention that a common question I get is on the difference between celiac disease and a food allergy. Well, a person with a wheat allergy experiences itchy or watery eyes or breathing difficulties upon consuming wheat. Someone with celiac disease, on the other hand, experiences symptoms more serious like abdominal pain and cramps, nausea and even nervous system symptoms.

Getting diagnosed early

It’s important to get a confirmed diagnosis as soon as possible as not only do you want to protect your small intestine and start making diet changes for a better quality of life, you want to avoid risking getting another autoimmune disease. For people with celiac disease, the later the diagnosis, the higher the chance of developing another autoimmune disorder. The most common autoimmune diseases associated with celiac disease are Type 1 diabetes and thyroid disease. This is because these disorders have similar immunological and genetic linkages with celiac disease. Other serious conditions and cancers may also be associated with celiac disease.

Based on the research, I would say that those diagnosed from ages 2-4 have a 10.5% risk; 16.7% for ages 4-12; 27% for ages 12-20; and 34% for those over 20. As you can see, the percentages triple depending on the period of diagnosis.

We don’t know yet what specifically triggers autoimmune disorders in the first place. For reasons not completely understood, about 75% of patients with autoimmune diseases tend to be women. What we do know however is that autoimmune disorders tend to run in families and might be linked to certain genes. So if you have a family member with celiac disease, you have about a 1 in 10 chance of getting it.

Managing your risks with a strict diet

By adhering to a strict gluten-free diet, you can heal the damage to your small intestine, prevent further damage and lower the risk of cancers and other diseases. This means eliminating all if not most cereals, grains, pasta and processed foods. As for oats, most doctors and dieticians in the past would advise against it, but there has been evidence that suggests a moderate amount is fine so long as the oats do not come into contact with wheat gluten during processing and are labelled as “gluten free”.

Fresh food like meat, fruits, vegetables, fish and rice without additives are all things you can consume. There are also many places in Singapore where you can find gluten-free bread and pasta. When shopping at the supermarket especially, always remember to read food labels — look out for terms like “gluten-free”, “without gluten”, “free of gluten” and “no gluten”.

I find that food that labelled gluten-free (e.g. certain kind of pastas) tend to be more expensive than food that are naturally gluten-free (e.g. meat, fish). But with practice and some help from a dietician, you’ll find it easier to lead a cheaper and easier gluten-free life stocked with yummy and natural options!

References

1. Lundin, K. E., & Wijmenga, C. (2015). Coeliac disease and autoimmune disease-genetic overlap and screening. Nature reviews. Gastroenterology & hepatology, 12(9), 507–515. https://doi.org/10.1038/nrgastro.2015.136
2. Buysschaert M. (2003). Coeliac disease in patients with type 1 diabetes mellitus and auto-immune thyroid disorders. Acta gastro-enterologica Belgica, 66(3), 237–240.

FOOD ALLERGY, GLUTEN INTOLERANCE AND CELIAC DISEASE

Some form of digestive disorder affects millions of people around the world. For some people, digestive disorders are a source of irritation and discomfort that may cause them to significantly limit their lifestyles and frequently miss work. For others, the disorders may be rather serious. Despite the fact that food and diet are central issues that concern many patients attending gastroenterology clinic, the current understanding and explanation about the association between the intake of certain foods/food groups and the gastrointestinal (GI) symptom pattern, psychological symptoms, and quality of life may not be simple and straightforward.

The gastrointestinal (GI) tract is a long muscular tube that functions as the food processor for the human body. The digestive system includes different organs working in close harmony to digest the food and absorb the nutrients. However, GI tract is not a passive system. Rather, it has the capability to sense and react to materials passed through it. For a healthy digestive system, every person requires somehow different food selections that match their GI tract capacity.

The GI tract breaks down foods by first using mechanical means (e.g., chewing) and then via the application of complex chemical processes (from saliva to colon microbes). Since the GI tract is the point of entry for the human body, everything eaten has an impact on the body. The food eaten and passed through the GI tract contains nutrients as well as non-nutritional additives and contaminants. Additives and contaminants can include, but are not limited to, food additives, pesticides, bacteria or chemicals that induce a reaction from the GI tract.

GI tract is very important sensory organ. By rejecting foods through objectionable taste, vomiting, diarrhea, or any combination of these symptoms, the sensing capacity of the GI tract can protect the body. The immune sensors in the GI tract trigger responses such as nausea, vomiting, pain, swelling and diarrhea. Vomiting and diarrhea are abrupt defensive responses when it senses foods or contaminant with a allergic or toxic component. This kind of food intolerance is responsible for many digestive problems.

Food allergy is sometimes the primary cause of GI tract problems. The dysfunction, discomfort, and disease associated with the GI tract can be the result of local immune responses to food selections or combinations of foods. Food selections are a result of personal tastes, social fads, ethnic culture, religion, and local or seasonal availability. Food selections made in modern society are based on a developed taste for a rich diet centered on meats and dairy products, high concentrations of proteins, simple carbohydrates, processed food and fat-soluble additives.

The effect of the shift in our diets during the past 100 years has resulted in increasing amount of people suffering from reflux, bloating, non-ulcer dyspepsia, diarrhea, constipation, diverticulosis, gallstones, fatty liver, and even a cancer.

Detailed medical history, evaluation of dietary habits and food selection and physical examination are the first modalities used in approach for evaluation of GI conditions. There are few basic symptoms indicating a GI tract problem.

Nausea and Vomiting

Nausea and vomiting can vary from an unsettled feeling in the stomach to the violent action of immediate vomiting. Nausea and vomiting are linked to may GI conditions and also to some non-GI disorders.

Bloating

Bloating can result from excessive gas in the digestive system due to fermentation and swallowing air while eating or failure of the digestive tract to break down nutrients into small absorbable molecules (e.g lactose intolerance or celiac diseases).

Constipation

Constipation is the decreased frequency or slowing of peristalsis, resulting in harder and infrequent stools. When the GI tract is slowed down, feces can accumulate in the colon with attending pain and bloating. It is often result of inadequate water and fiber intake and increased intake of processed and fatty food.

Diarrhea

Diarrhea is the increased frequency of bowel movements, which are also loose or watery. Diarrhea could be associated with food allergy or celiac disease, but is also present in other inflammatory bowel conditions or irritable bowel.

Abdominal Pain

Abdominal pain appears in different patterns and with varying intensities. It is a common symptoms of various GI problems.

What is (a) gluten intolerance, and (b) coeliac disease? What are the symptoms that you see? What is the treatment?

Celiac disease is an immune-based reaction to dietary gluten (storage protein for wheat, barley, rye) which affects the small intestine in those with a genetic predisposition and resolves with exclusion of gluten from the diet. There has been a substantial increase in the prevalence of celiac disease over the last 50 years and an increase in the rate of diagnosis in the last 10 years.

Celiac disease is one of the most common causes of chronic malabsorption. This results from injury to the small intestine with loss of absorptive surface area, reduction of digestive enzymes, and subsequently impaired absorption of micronutrients such as fat-soluble vitamins (A,D,E,K), iron, and vitamin B₁₂, folic acid, zinc, etc. In addition, the inflammation worsens symptoms of malabsorption by causing secretion of fluid into the intestine that can result in diarrhea. The failure of absorption of adequate calories and nutrients leads to weight loss, and the malabsorption results in abdominal pain and bloating.

Therefore, celiac disease can present with many symptoms, including typical GI symptoms (e.g., diarrhea, oily stools, weight loss, bloating, flatulence, abdominal pain) and also non-gastrointestinal abnormalities (e.g., abnormal liver function tests, iron deficiency anemia, bone disease, skin disorders, itchy skin rash and many other manifestations). Indeed, many individuals with celiac disease may have no symptoms at all.

Celiac disease is usually detected by blood test - testing of specific gene carrying the predisposition and celiac-specific antibodies. The diagnosis is confirmed by small intestine (duodenal) mucosal biopsies taken during gastroscopy. Both blood test and biopsy should be performed when patient is taking gluten containing diet. When someone is on gluten-free diet, antibodies blood test and biopsies could be only done after daily exposure to gluten for at least 3 weeks.

The treatment for celiac disease is primarily a gluten free diet, which requires significant patient education, motivation, and follow-up.

Non-celiac gluten sensitivity or simply gluten sensitivity is defined as "a clinical entity induced by the ingestion of gluten leading to intestinal and/or extraintestinal symptoms that improve once the gluten-containing foodstuff is removed from the diet, and celiac disease and wheat allergy have been excluded".

The pathogenesis of non-celiac gluten sensitivity is not yet well understood. Non-celiac gluten sensitivity is a controversial clinical condition and some authors still question it. Non-celiac gluten sensitivity is the most common syndrome of gluten-related disorders with prevalence rates between 0.5–13% in the general population.

However, at this time, it appears that non-celiac gluten sensitivity does not have a strong hereditary basis, is not associated with malabsorption or nutritional deficiencies, and is not associated with any increased risk for auto-immune disorders or intestinal malignancy. There is no specific blood test for diagnosing this condition, so diagnosis is made by exclusion of other gluten-related disorders, namely by excluding celiac disease and wheat allergy.

Why food allergies are becoming more and more common?

Celiac disease is a chronic inflammatory disorder of the small intestine, produced by the ingestion of dietary gluten products in susceptible people. It is a multifactorial disease, including genetic and environmental factors. Environmental trigger is represented by gluten while the genetic predisposition has been identified on certain parts of our genetic material (HLA DQ2 and DQ8). Celiac disease is not a rare disorder like previously thought, with a global prevalence around 1%. The reason of its under recognition is mainly referable to the fact that about half of affected people do not have the classic GI symptoms, but they present nonspecific manifestations of nutritional deficiency, autoimmune conditions, irritable bowel or have no symptoms at all.

There has been a substantial increase in the prevalence of celiac disease over the last 50 years and an increase in the rate of diagnosis in the last 10 years. The reasons for increasing frequency of celiac disease are unclear but could be related to recent dietary changes, gluten-rich dietary patterns,  processed foods, microbiota etc.

Celiac disease was originally thought to almost exclusively affect white Europeans. The frequency of celiac disease risk HLA genotypes is about 30%, whereas only 1%-3% develops celiac disease. The prevalence varied geographically, higher in Northern Europe and the African Saharawi region than in South-East Asia. However, recent epidemiological studies conducted in areas supposedly free of celiac disease, including Africa, the Middle East, India, and South America, showed that the disease was previously underdiagnosed.

The world distribution of celiac disease seems to have followed the mankind wheat consumption and the migratory flows. Man originally fed on meat, fruit and vegetables, with no exposure to gluten-containing cereals. It was only about 10 000 years ago in a small region called the “Fertile Crescent” of the Middle-East (including Anatolia (Southern Turkey), Lebanon, Syria, Palestine and Iraq) where wild wheat and barley grains successfully cultivated due to favourable environmental conditions. In the Fertile Crescent some tribes changed from nomadic to stable settlement style of living because land cultivation permitted food storage, and later migrated westwards to obtain new lands for cultivation. These persons spread through the Mediterranean area (Northern Africa, Southern Europe) and Central Europe. The expansion continued from 9000 to 4000 BC by which time the cultivation of wheat and barley had spread all over the Old Continent, also reaching Northern Europe (Ireland, Denmark and the Scandinavian countries). This expansion in farming was due to the diffusion of agricultural practices and replacement of local inhabitants.

"Gluten sensitivity" has become commonplace among the public. Wheat allergy and celiac disease are well-defined entities, but are becoming only a fraction of individuals following a gluten-free diet.

Wheat allergy has a prevalence of <0.5%. Wheat is the most common allergen implicated in food-dependent, exercise-induced anaphylaxis. Celiac disease is hypersensitivity to gluten in genetically predisposed individuals. In addition to suggestive symptoms, serologic testing has high diagnostic reliability and biopsy is a confirmatory procedure.

However, many people follow gluten free diet as a consequence of media and industry, without appropriate medical evaluation and testing. There is a huge misconception about gluten free diet. It is essential for people diagnosed with celiac disease. However people without this condition often mistakenly adopt “gluten free diet” and consuming gluten free food in belief it is “healthier.

The gluten-free food is sometimes promoted as a way to lose weight, or as a “healthier” food. There is no evidence that gluten free food is beneficial for people who do not have celiac disease. Not only that. Gluten free food is not the same as staying gluten free. Patients with celiac disease are aware about this difference and they avoid commercially prepared gluten free food substitutes and focus their diet on naturally occurring food choices which do not contain gluten.

However, commercially prepared gluten-free food contains dietary substitutes and additives which are usually not healthy. Misconception is that eating gluten-free food leads a healthy lifestyle. The average commercially made gluten-free food is highly processed and containing lots of additives. The biggest problem with the “Gluten-Free Diet” in general population without proper guidance is the reliance on these commercially prepared processed foods that are low in nutrients and high on additives.

The standard commercially prepared Gluten-Free Food typically contain several specific food components:

• Cereal grains (corn, rice, soy)
• Seed oils (Canola oil, Rapeseed oil, safflower oil, and sunflower oil)
• Sugar (high-fructose corn syrup)
• Artificial sweeteners
• Food additives (xanthan gum, guar gum, soy substitutes)

Even though gluten was removed – the Gluten-Free commercially prepared food relies heavily on the other agents, additives and substitutes. In fact, many types of commercially prepared gluten-free foods are loaded with higher concentrations of food additives than their original counterparts.

The recommendation would be, if someone suspect any food intolerance or allergy, get proper medical evaluation and testing to avoid further health problems.

IDENTIFY THE SAFER FOOD

ALLOWED FOOD  

• Rice
• Buckwheat
• Amaranth
• Corn and cornmeal
• Gluten-free flours (rice, soy, corn, potato, quinoa, bean, garbanzo, flax)
• Hominy (corn)
• Millet
• Quinoa
• Sorghum
• Soy
• Tapioca
• Teff
• Banana or coconut or nuts or chestnut flours
• Tubers (potato, sweet potato, mexican potato, manioc, topinambur, arrowroot, cassava)
• Fresh meats, fish, seafood and poultry (not breaded, batter-coated or marinated)
• Fresh eggs
• Most dairy products (unless lactose intolerance)
• Fresh Fruit
• Vegetables
• Legumes (chickpeas, beans, lentils, peas, soybeans and Job’s Tears also known as Chinese Barley), seeds and nuts in their natural, unprocessed form. If you purchase dried beans, a good rinse before cooking will remove any possible cross contamination.
• Herbs and spices: All stand-alone herbs and spices are gluten-free. Whenever possible, purchase fresh varieties or grind at home. Check with manufacturers for pre-ground dried spices. McCormick and Natco are two companies that minimize any cross-contamination risk. Ginger, galangal, curry leaves, laksa leaves, fresh chilis, lemongrass basil, thyme, sage, rosemary, etc.. are all part of a gluten-free diet.

NOT ALLOWED FOOD

Avoid all food and drinks containing:

• Atta
• Barley (malt, malt flavoring and malt vinegar are usually made from barley) barley coffee
• Bulgur
• Cous cous
• Durum flour
• Emmer
• Einkorn
• Farina
• Graham flour
• Hydrolyzed wheat protein
• Kamut
• Rye
• Semolina
• Spelt
• Triticale (a cross between wheat and rye)
• Wheat, wheat bran and wheat germ

CAUTION FOOD

Avoid unless labelled 'gluten-free'
In general, avoid the following foods unless they're labelled as gluten-free or made with corn, rice, soy or other gluten-free grains:

• Baked goods: pineapple tarts, cakes, cookies, pie crusts, etc..
• Beer: (unless explicitly gluten-free) and any malt beverages
• Breads and sourdough bread: roti prata, bao, croissants, pita, naan, bagels, flatbreads, cornbread, potato bread, rolls, croutons, flour tortillas, panko, breadcrumbs
• Breakfast Foods: pancakes, waffles, toast, crepes, bagels, cereal, Milo and biscuits.
• Brewer’s yeast
• Candies (all) and Cookies
• Cappuccinos or hot chocolate (chocolate drink powders may contain wheat starch)
• Cereals & Granola: always check ingredients. Malt extract/flavoring, oats and wheat are all common ingredients.
• Crackers and croutons: pretzels, goldfish, graham crackers, table crackers, water crackers
• Food additives, such as malt flavoring, modified food starch and others
• French fries
• Gravies
• Imitation meat or seafood
• Matzo
• Noodles: ramen udon, soba (most are made with a combination of wheat and buckwheat flour), spaghetti, and egg noodles.
• Pasta and pizza and pastries (muffins, donuts, croissants, et..)
• Processed luncheon meats
• Sauces: salad dressings (including balsamic vinegar), soy sauce oyster sauce, hoisin sauce, teriyaki sauce, cream sauces made with a roux, any gravy using wheat flour as a thickener
• Seasoned rice mixes
• Seasoned snack foods, such as potato and tortilla chips
• Self-basting poultry
• Soups and soup bases
• Stock cubes or powder
• Tempura
• Vegetables in sauce or coated with not allowed flour
• Wheat starch
• Medications and vitamins that use gluten as a binding agent
• Certain grains, such as oat, can be contaminated with wheat during growing and processing stages of production. For this reason, it is generally recommend avoid oats unless it is specifically labelled gluten-free.

Replacements

Common gluten containing ingredients that should be replaced with a gluten-free version:

• Soya (soy) sauce: gluten-free soy sauce or wheat-free tamari
• Oyster sauce: gluten-free versions are available
• Teriyaki sauce: gluten-free versions are available
• Hoisin sauce: gluten-free versions are available
• Wheat pasta: rice, corn, beans, quinoa or buckwheat pasta
• Cookies, crackers, bread: gluten-free versions
• Wheat flour: gluten-free flour blend (Bob’s Red Mill One to One, Yes You Can, Orgran, etc. are all common brands available in Singapore)
• Beer: gluten-free beer. Wine and distilled spirits are gluten-free (beware of flavorings)

READING FOOD LABELS

STEP 1: LOOK FOR “GLUTEN FREE” LABEL

• Gluten free symbol assure that the product contains less that 20 parts per million (PPM) of gluten from all sources, including ingredients and cross-contamination.

For people with celiac disease the level of less than 20 PPM is adequate for a long term safety and health.

• Special Certification: Special certification can be present on the product and helpful to give an added level of assurance.

STEP 2: READ THE INGREDIENTS

Look for these most common ingredients, especially in products not labelled gluten free:

• Wheat: must be declared in allergen label.
• Barley: Malt, malt extract, malt syrup and malt flavor.
•  
• Brewer’s yeast.
• Oats: If product it is not labelled GF.

à Manufacturers are not allowed to list “ gluten free oat” in the ingredients list, but the product should be labelled GF.

OTHERS NAME FOR GLUTEN

• Atta (chapati flour)
• barley (flakes, flour, pearl)
• breading
• bread stuffing
• brewer’s yeast
• bulgur
• durum
• einkorn (type of wheat)
• emmer (type of wheat)
• farro/faro = spelt
• farina = flour
• fu
• graham flour
• hydrolyzed wheat protein
• kamut
• malt
• malt extract
• malt syrup
• malt flavoring
• malt vinegar
• malted milk
• matzo
• matzo meal
• modified wheat starch
• oatmeal
• oat bran
• oat flour
• whole oats (unless they are from pure, uncontaminated oats)
• rye
• rye flour
• seitan
• semolina
• spelt
• triticale
• wheat bran
• wheat flour
• wheat germ
• wheat starch

SOME TRICKY INGREDIENTS

Maltodextrin: usually GF in USA because made with corn. But in other countries and sometimes also in USA, it can be made by wheat. If you are not sure about the source, please choose in products labelled GF.

Yeast extract: typically is not GF unless grown on sugar beets which are gluten-free. If you are not sure about the source, please choose in products labelled GF.

Caramel color: Usually made by corn or wheat. The product is so highly processed that generally it can be considered GF. For more precaution, choose in products labelled GF.

Natural flavoring: typically GF but sometimes they can be made using other allergens or they can be contaminated with wheat. If you are not sure about the source, please choose in products labelled GF.

Modified food starch: typically GF in USA, unless product states contains wheat. Usually it is made from corn, tapioca or potatoes. If it is made from wheat, barley or rye they have to mention it on the label. If you are not sure about the source, please choose in products labelled GF.

Wheat starch modified to remove gluten: the product is so highly processed that generally it can be considered GF. For more precaution, choose in products labelled GF.

Dextrin: typically GF in USA, unless product states contains wheat. But in other countries it can be made by wheat. If you are not sure about the source, please choose in products labelled GF.

Distilled vinegar and alcohol: Usually they are considered GF because distillation process removes all the proteins. If not sure about alcohol products, please follow this advice:

• Avoid beer unless it is specifically brewed to be gluten-free
• Avoid ciders
• Rum, tequila, vodka, whiskey, gin, bourbon and other distillates are considered gluten-free, unless they are added with flavor (eg. Strawberry wodka, etc… choose always the plain version)
• Wine is typically gluten-free and safe to drink

STEP 3: GENERAL RULES

• Choose products with a short ingredients list, to check more easily if there are gluten-containing ingredients.
• If possible, purchase naturally gluten free food instead of packaged and processed foods. Remember that available processed/flavoured versions may have gluten-containing ingredients.
• Products labelled “wheat-free” are not necessarily gluten free. Remember to read all the ingredient in the list.
• Remember that regulations on gluten free vary from country to country, so sometimes a product made in USA without gluten is made from the same company in another country but with different ingredients. As a general rule, always read the ingredients list and choose in products labelled GF.
• When in doubt, purchase products that are labelled gluten free.
• Avoid products that do not list the source of dextrin, starch or flavor on the product label.
• Please always choose products labelled gluten-free and also preferably certified gluten-free by a third party.
• Products that are labelled gluten-free coming from Australia, New Zealand, Europe and the United States are required to follow strict protocols to be able to use a gluten-free label on products. In other countries, the regulation it is not so strict, so if in doubt, email or phone manufacturers and food producers.

STEP 4: CHECK MANUFACTURING ADVISORY STATEMENTS

NOTE: This a voluntary label that it is not required on foods.

• The absence of such a statement does not mean it is made in an allergen-free facility.
• The presence of such a statement does not mean it contains the allergen.

So what do I do?

• Whenever possible, choose naturally gluten-free grain-based products labelled gluten-free or made in dedicated facility to avoid cross-contact risk.

PREVENT CROSS CONTAMINATION

STEP 1: SEPARATE THINGS AT HOME and when DINING OUT

Home

• It is not recommended to purchase grains from bulk bins because of the possibility for cross-contact with gluten.
• Carefully clean common surface, work tools and utensils before starting to cook.
• Do not use hard to clean equipment for both gluten-free and gluten-containing foods (for example use different cutting board or wood utensils).
• Toasters, strainers and flour sifters should not be shared.
• Wash your hands thoroughly before handling gluten-free ingredients
• If you can prepare gluten free and gluten-containing foods at different times, give the priority to gluten-free ones.
• Deep-fried foods cooked in oil also used to cook breaded products should be avoided.
• If you are using spreadable condiment in shared containers, don’t use the same knife or teaspoon for both product with and without gluten, because of the risk of contamination of the sauce.
• Wheat flour can stay airborne for long time contaminating food, surface and utensils, so please clean everything before starting to cook.
• Use two different packs of salt while cooking because most of the time you take a pinch of salt for both gluten free and non gluten free products and you may have a contamination.
• When you put bread with gluten on the table, do not place it on the tablecloth, but in a basket or plate.
• Use baking paper for baking trays, grills and pans where contamination may be present and clean at the end removing all crumbs and residuals.
• Store gluten free products (pasta, flour, etc.) in a box in a different place from those containing gluten.

Dining out

• Make sure that separate fryers, pasta water, woks, toasters, steamers, pans for eggs and pancakes are available.
• Avoid loose, airborne flour in a shared bakery or pizzeria. Make sure that they have methods to separate and that they don’t prepare the products at the same time.
• Always ask questions like: How do you prevent cross-contamination with gluten in your kitchen?

GLUTEN FREE SHOPS SINGAPORE

• Sasha’s fine foods (online shop)
• Ryan’s Grocery (grocery) à good variety of bread and crackers
• Kiwi Kitcken (online shop)
• The Gluten free Singaporean (bakery)
• Supernature (shop)
• The Whole Kitcken (bakery) à good variety of bread and crackers
• com (online shop)
• Phoon Huat (baking supplies)
• The great beer experiment (Beer)
• The Organic Frog (online shop) à good variety of bread and crackers
• Cookit SG (online shop)
• Baker & Cook (bakery) à good variety of bread and crackers
• Bakening (bakery)
• Rosa Our Littlest Kitchen (ice cream)
• Smoocht (ice cream)
• Delcie's Desserts & Cakes (cake shop)

GLUTEN FREE RESTAURANTS SINGAPORE

• Tiann’s
• Margarita’s Dempsey Hill
• Ocha Fresh Thai
• Entre Nous
• Glow
• Superfudo
• Amò
• Kitchen by Food Rebel
• The living Café
• The Butcher’s wife
• Bread Street Kitchen