April 10, 2009 -- Global cuisines can be a delicious way to experience different cultures. Part of the fun is seeing how different people use exotic and familiar ingredients in uncommon ways.
But this practice can pose risks for those with food allergies. As the ingredients in a dish become less obvious, the potential to eat an unexpected allergen increases.
"Just because you think that a food is OK, you cannot assume," said Dr. Anna Nowak-Wegrzyn, assistant professor of Pediatrics at the Jaffe Food Allergy Institute at the Mount Sinai School of Medicine in New York.
Nowak-Wegrzyn noted that peanut butter can show up in Asian spring rolls. "It's not very intuitive," she said.
While food allergy experts say that people with allergies should apply the same degree of caution to ethnic foods as any other food they might eat, language barriers, unknown ingredients and different preparation techniques can magnify the challenge to express needs and concerns.
And imported products can increase the risk of ingesting something unknown, although Ming Tsai, an allergy advocate and owner of Blue Ginger restaurant in Wellesley, Mass., said that most manufacturers require a clear list of ingredients on their products.
But if the standards of a country's labeling system are unclear, erring on the side of caution is better.
"You do need to be a little bit more careful," Tsai said. "With kids, I wouldn't use an exotic foreign spice rub, just to make doubly sure. It's better to be safe than sorry."
"Still, the common allergens remain common," said Dr. Jacqueline Pongracic, division head of Allergy and Immunology at Children's Memorial Hospital in Chicago, Ill., referring to the eight most common allergies: fish, shellfish, milk, egg, soy, wheat, peanuts and tree nuts, including walnuts and cashews.
Proper preparation before visiting an ethnic food restaurant can help allay fears and avoid unnecessary allergic reactions. Researching common ingredients in the cuisine can point out obvious allergens to avoid. Thai food, for example, incorporates a variety of of peanut products while Mexican and Italian foods use cheese to flavor and garnish dishes.
It can be helpful to know if different countries use different terms for certain ingredients or cooking techniques. For example, in Africa, peanuts are often called groundnuts. In Chinese, "shu" means "barbecued" and "kow" means "roasted" while "al horno" means "baked" in Spanish and "frito" means "fried." Knowing such terms can offer clues as to how an item might be prepared and whether it may contain and allergen.
Chef cards containing a list of allergenic foods can be ordered online in many languages and can help significantly in communicating needs between the diner and the kitchen staff.
"I believe in doing your homework," said Sloane Miller, a food allergy coach who blogs at allergicgirl.com.
And when in doubt, particularly with children, experts recommend keeping it simple.
"The child can start very young with very simple foods. Stay with foods that work and enjoy the social activity in that restaurant," said Anne Munoz-Furlong, founder of the Food Allergy and Anaphylaxis Network. "It takes the focus off the food but you are still exposed to the culture."
Keeping medication handy and eating with a buddy who is aware of your allergy needs is essential, particularly when trying unknown foods. And when in doubt about a food situation, allergy experts advise leaving.
"Accidents occur when you least expect, so be prepared to institute the treatment plan to help you remedy the situation should an allergic reaction arise," Pongracic said.
The following pages show which common allergens can be found in some ethnic foods.
Asian cuisines, from Japanese and Chinese to Thai and Korean, vary in flavor but share several of the big eight allergens as ingredients, in particular, peanuts, fish and shellfish, soy and eggs.
In addition to cooking with several major allergens, common foods are often incorporated into Asian dishes in uncommon ways. For example, the casings of fried egg rolls or spring rolls can be sealed with peanut butter. Those with peanut allergies may not see peanuts in the menu description, but they are still part of the dish.
Of all the Asian cuisines, Thai food is particularly peanut rich. The legumes are used for flavoring, thickening, and garnishing many dishes, such as pad thai rice noodles.
Cross contamination can be an issue for those with allergies when it comes to Asian cooking techniques. Woks, for example, are not meant to be soaped in between so that they can be seasoned over time with the flavors and oils of foods cooked in them. But if a person with a shellfish allergy is served a seafood-less dish made in a wok that was used to cook shrimp, some shellfish proteins can contaminate the food and lead to a reaction.
"I've ordered a vegetarian dish and it showed up with a claw," Miller said. "It was made in the same wok."
Re-used cooking oil can also contribute to cross contamination of allergens with other foods.
In these cases, clear communication between diner and restaurant staff is critical and a card listing specific allergens can be helpful.
Interestingly, soy sauce, ubiquitous in Asian restaurants, is usually well tolerated by those with a soy allergy because the soy proteins are broken down by the fermentation process. Wheat is a larger problem in soy, tamari or fish sauce condiments because those can contain gluten proteins.
"Reading the label is the most important thing," Tsai advised. "Or at the restaurant, get the manager or chef to read it for you."
French food, from the seafood rich dishes of the north to the Provençal fare of the south, has a certain je ne sais quoi. But that indefinable kick could spell trouble for those with allergies.
The emphasis on fresh, local cuisine gives the French a variety of vegetables to work with but salad dressings and vinaigrettes can be a hidden source for nut and seed oils and eggs. Expensive, hand-pressed oils -- walnut, almond and sesame, for example -- used for their intense flavors, can be more allergenic than the cheaper, refined oils because they contain more nut proteins.
Mustard and mustard seeds, a common ingredient in French cooking, is a growing concern in France, Nowak-Wegrzyn said. A 2003 French study reported that mustard allergy accounts for 1.1 percent of food allergies in children, according to the journal Allergy.
"The more a particular food is being used, the more you have the potential to see the reaction," Nowak-Wegrzyn said.
Malt vinegar, a common table condiment often sprinkled over pommes frites (French fries), is made of undistilled fermented barley. Those with a wheat allergy should avoid malt vinegars because they contain gluten -- wheat proteins.
Rich, creamy dishes such as béchamel pastas, bisque soups and crème brulee are signature French fare, as are cheeses, but should be avoided by those allergic to dairy.
The classic French duck or goose liver delicacy known as foie gras can be another source of hidden allergens. Although French law requires foie gras to contain about 80 percent liver, the rest can be a combination of other meats, as well as eggs, corn or soy oil and nuts.
Fortunately, champagne and white and red wine are free of the eight most common allergens, and unless the sulfites found in red wine are hive-inducing, an allergen-free meal with a good bordeaux or sauvignon blanc should be tres bien!
If any theme could unify the diversities in Indian cuisine, it may be the judicious use of spices.
Some of the most common spices are ground up and mixed into masalas as a flavorful base for vegetable and meat curries, rice and almost every other savory dish, include bay leaves, coriander, cardamom, fenugreek, ginger, garlic and turmeric.
"The biggest [allergy] risk is not going to be spices for the majority of people," Munoz-Furlong said, because while the classic spices themselves are not typically allergenic, masalas, which can vary from household to household, can be a risk.
Sloane Miller recalled a restaurant she went to that told her they used "just a little bit" of hazelnut in their masala.
"Isn't [masala] the basis for everything?" said Miller, who is allergic to tree nuts. "That can't be good."
People with allergies to dairy products, peanuts and tree nuts should be wary of creamy curry sauces that often include cream and are thickened with a cashew or almond paste. Menu items with the word "malai" signal a creamy sauce.
Lentils and legumes, a major source of protein in a country with a large vegetarian population, can also trigger an allergy. Allergies to chickpeas or garbanzo beans are prevalent in India, according to a 2001 study in the Annals of Allergy, Asthma, and Immunology.
Another unifying custom in India is afternoon tea. While the plain varieties are unlikely to contain allergens, those allergic to milk should avoid masala chai, a spiced, sweetened tea made with hot milk.
Indian desserts such as kheer, a milky rice pudding, and kulfi, a rich ice cream, are also typically milk based and nut-heavy. If the local fruits do not trigger an allergic reaction, then a mango or a custard apple can help satisfy a sweet craving.
Italian food has become pervasive and evolved its own culture in the United States. While it may be difficult to imagine allergens lurking in a simple dish of spaghetti with tomato sauce, many common ingredients in Italian food can be highly allergenic.
Cheese and dairy products, used liberally in Italian cooking, should be avoided by those allergic to dairy. Cross contamination can be a risk if fettuccini pasta, for example, were cooked in the same water as cheese ravioli.
Breads and pastas are an important food and vehicles for sauce in Italian cooking and those with a wheat allergy or intolerance could feel excluded from the culture. But the variety of gluten-free pasta and bread products now available make tasty substitutions for those with allergies easy.
Breaded and fried items, such as mozzarella sticks or eggplant, can be more problematic because breading mixes can contain wheat, seeds and nuts, which can trigger allergies.
Pesto sauces also contain nuts, usually the small, creamy white pine or pignoli nuts, but walnuts are also used.
"The best thing to do is order simply prepared food," Munoz-Furlong said. "Baked, served with sauce on the side, and avoid casseroles where you don't know what's in the food until you're eating it."
Unlikely places to find allergens are the light, sweet shaved ice desserts called granite. The flavored syrups topping granite can contain corn, soy and nuts, if the syrup is flavored with almond or hazelnut, for example. Granite syrups can also contain milk as a flavoring, as can gelato, the Italian ice cream
"It's important not to assume that, because it doesn't look creamy, that it wouldn't contain milk protein," Pongracic said.
From ranchero to adobo to mole, Mexican food is saucy, and while they add flavor and spice, sauces can be problematic for those with allergies.
"Mexican foods use a lot of sauces," Munoz-Furlong said. "That's where you're going to find your hidden allergens."
Because sauces and dips, such as guacamole, can vary in their ingredients, Munoz-Furlong suggests finding out exactly what is in a sauce before eating it. For example, mole, a cocoa based sauce from the states of Puebla and Oaxaca typically served with turkey or chicken, uses a cornucopia of ingredients including chiles, cinnamon and garlic, and it may not be suitable for people with nut allergies because the sauce often contains nuts.
Beans, or frijoles, used in Mexican food -- black beans or pinto beans -- are well tolerated by most people, Nowak-Wegrzyn said, even those for whom peanuts, soybeans, chickpeas or lentils may be a problem.
And those with soy or wheat allergies should think twice before downing a shot of rum or tequila as they may contain those allergens.
One of the most prominent allergens in African cuisine is peanuts, often referred to as groundnuts. They are used in soups, stews and as sauces for meat and rice dishes.
"They are wonderful flavors but you don't know what you're eating," Munoz-Furlong pointed out. "You don't always know what the name of the food might translate to."
But African food can be friendly for those with a wheat allergy or intolerance. Millet, one of the staple starches in many parts of Africa, a cereal crop eaten like rice with stews or meats, is far removed from the wheat family and can be eaten by those with allergies.
Cornmeal, another staple that has different names all across Africa, including ugali in Kenya, sadza in Zimbabwe and fufu in West Africa, is another starchy alternative for those with a wheat allergy.
Encompassing the foods from most of the countries in and around the Mediterranean Sea, Middle Eastern cuisine is known for earthy flavors balanced by citrus and herbs, with liberal amounts of olives and olive oil.
But while they pack a lot of healthy omega-3 fatty acids, the seeds and nuts prevalent in Middle Eastern cooking may be the biggest allergy inducing culprits in the cuisine.
Sesame seeds are particularly pervasive in Middle Eastern foods, whole, as oil or ground up into a thin sauce called tahini, which is found in many dishes and used as a dipping sauce for foods such as the spicy chickpea cakes known as falafel.
"I'm noticing that more and more children are being introduced to pureed dishes that are made with tahini, like hummus," Pongracic said. "People, rightly, think it's nutritious and it tastes good so it will be good for their child ... don't forget to ask what's in the food."
Middle Eastern sweets also contain seeds and nuts and should be avoided by those with nut allergies. Baklava, a pastry made of layers of thin fillo dough and drizzled with honey, often contains pistachios or walnuts.
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