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Lactose Intolerance Lactose intolerance develops when the body has difficulty digesting whole and skim milk and other dairy products. Lactose is a milk sugar and like most sugars, it is broken down by enzymes in the intestinal tract so it can be absorbed as an energy source. The enzyme that breaks down lactose is called lactase. When the intestine does not contain lactase, then lactose intolerance can occur. It is a troublesome and annoying problem, but it is never a serious one. Who Has Lactose Intolerance? As commonly expected, infants and small children have the enzyme lactase so they can digest mothers' milk. However, during childhood, lactase begins to disappear in many people. Some ethnic groups are more likely to develop lactose intolerance. By adolescence, it is gone in about 75% of African-Americans, Jews, Native Americans, Hispanic persons, and in 90% of Asians. So the condition is very common. What Are The Symptoms? When undigested lactose reaches the colon (large intestine), it is broken apart by bacteria. Lactic acid and other acidic chemicals result. It is these products that create the symptoms of lactose intolerance. These symptoms include nausea, abdominal cramps and rumbling, bloating, rectal gas (flatus), and diarrhea. They usually occur 30 minutes to two hours after ingesting lactosecontaining foods. The severity of symptoms usually depends on the amount of lactose ingested and how much of the enzyme, lactase, remains in the intestinal tract. The Diagnosis First, the physician reviews the patient's medical history. Sometimes that is enough to determine the problem. However, to make a definitive diagnosis, one of several tests may be needed: Lactose Tolerance Test - A test dose of lactose is ingested and blood sugar determinations are made over several hours. If lactase is present to break down the lactose load, then the blood sugar level rises. If no lactase is present, the blood sugar level does not change. Hydrogen Breath Test - When lactose is broken down by the colon's bacteria, hydrogen is released, which then passes out through the lungs. The amount of hydrogen released after a lactose meal can indicate a problem. Stool Acidity Test - When lactose breaks down to lactic and other acids in the colon, the resulting acidity can be detected by a simple measurement of stool acidity. The Home Do-It-Yourself Test - Since lactose intolerance is not a serious disorder, some people may want to test themselves at home. First, avoid milk and lactose-containing foods for several days. Then on a free morning, such as a Saturday, drink two large glasses of skim or low-fat milk (14-16 oz). If symptoms develop within four hours, the diagnosis of lactose intolerance is fairly certain. Treatment Therapy depends on whether a patient is willing to tolerate the symptoms. If the symptoms are mild, then avoiding large amounts of milk and milk products may be enough. For those who are very sensitive to small amounts of lactose, there are two options. First, all foods should be carefully checked for lactose. Grocery items such as bread, baked goods, cereals, instant potatoes, soups, margarine, lunchmeat, salad dressings, pancakes, biscuits, cookies, and candy can contain hidden lactose. Even prescription and over-thecounter drugs may contain lactose. The patient must become a label reader looking for and avoiding "milk" and "lactose". The second option is buying milk to which lactase, the enzyme, has been added. Lactase drops or tablets are also available which can be placed in milk. A pharmacist or food store manager can provide advice. There are over-the-counter lactase tablets that can be taken with meals to replace the enzyme the body no longer has. Finally, a variety of lactose-free products are now available in the specialty section of food stores. Calcium and Lactose Milk is a major source of calcium and calcium is necessary for good health and strong bones. Most people need 1000 mg of calcium a day, except for pregnant and nursing females (1200 mg per day) and post-menopausal females (1500 mg per day). The following list from the National Institutes of Health provides some information on the calcium and lactose contents of food. For the lactose-intolerant individual, ingesting enough calcium may be difficult. Calcium supplements, such as calcium carbonate, are often recommended. The decision to take calcium supplements should be discussed with the physician. Lactose-Free Low-Lactose Diet Purpose Lactose is the simple sugar found in milk and milk products. It can also be found in a variety of other foods and even as a filler in some pills and capsules. The enzyme lactase, present in the lining of the small intestine, splits lactose into two simple sugars. These simple sugars can then be absorbed by the body and used as nourishment. In infants, milk is the main part of the diet, so it is natural and normal for lactase production to gradually decrease as the diet becomes more varied. This tends to occur in childhood and adolescence in African Americans, Native American Indians, Hispanics, Arabs, Jews, and Asians. Northern European white races seem to keep lactase production the longest. When lactase is absent, lactose passes through the intestine to the colon (large bowel), carrying extra fluid with it. In the colon, bacteria break down lactose into lactic acid and certain gases. Lactic acid is an irritant and laxative. It can cause symptoms such as bloating, diarrhea, abdominal cramps, and gas or flatus. Lactase activity is reduced in people with certain intestinal conditions such as Crohn's disease and celiac disease (gluten enteropathy). Patients taking certain drugs and alcoholic patients may also be lactose intolerant. Finally, patients with surgical removal of part of the stomach or a large portion of the small intestine may need to reduce lactose in the diet. It is important to remember that while lactose intolerance can cause quite uncomfortable symptoms, it does not cause damage to the intestine. The purpose of this diet is to eliminate lactose or reduce it to tolerable levels. Nutrition Facts Dairy products are important sources of calcium, riboflavin, and vitamin D. Some lactose-intolerant people are able to tolerate certain dairy products in small amounts, and their diets may provide enough of these nutrients. However, the physician or registered dietitian may recommend certain vitamin supplements and/or a calcium supplement for some patients. Special Considerations Tolerance of lactose is variable. Some people can eat small amounts of lactose without having symptoms while others need to avoid it completely. Low-lactose diet: generally eliminates only milk and milk products. However, some can tolerate milk in small amounts (2 oz) throughout the day or as part of a meal. Some can tolerate small amounts of yogurt. These patients can experiment to find a level of lactose they can tolerate. Some people can build up their level of tolerance by gradually introducing the lactose-containing foods. Lactose-free diet: all lactose producst must be eliminated, including foods that are prepared with milk, both at home and in commercially packaged foods. These people may be able to use 100% lactose free milk or soy milk. Labels should always be read carefully. Lactase Digestive Aids and Products: Many people can drink milk in which the lactase has been partially or completely broken down. The following products may be available at a pharmacy or grocery store. LACTAID and Dairy Ease enzyme products - check with a pharmacist, registered dietitian, or a physician for individual guidance on the use of these products. Drops: These are added to milk. Five, 10, or 15 drops per quart of milk will generally reduces lactose content by 70%, 90%, or 99% respectively over a 24-hour period Caplets/Capsules: A person chews or swallows 1 to 6 of these when starting to eat foods containing lactose LACTAID Milk Non-fat or 1% low-fat is 70% lactose reduced Non-fat calcium-fortified is 70% lactose reduced and 500 mg of calcium per cup has been added Non-fat LACTAID 100 is completely lactose free DAIRY Ease Milk Available in non-fat, 1%, or 2% low-fat - all are 70% lactose reduced SOY Milk Calcium-fortified soy milk has no lactose, is low in fat and is a good source of Vitamin D. For more information about these products, call the consumer information number listed on the food label. The physician, pharmacist, or registered dietitian may also have information about these products or any newer products now available. Food Groups Group Lactose-Free Lactose-Containing Milk & milk products 100% lactose-free milk, soy milk milk: whole, skim, 1%. 2%; buttermilk; sweet acidophilus milk; lactose-reduced milk; evaporated milk; acidophilus milk; sweetened condensed milk; instant hot chocolate and cocoa mixes; cheese Vegetables fresh, frozen, and canned vegetables without added milk or milk products; tomato paste and purée; tomato and spaghetti sauces without cheese creamed or breaded vegetables, packaged dried potato mixes, tomato and spaghetti sauce with cheese Fruits fresh, frozen, canned, and dried fruits none Breads & grains water-based breads (Italian, French, Jewish rye), rice and popcorn cakes, graham crackers, rusks, Pareve-Jewish bakery products, cooked and dry cereals without added milk solids, pasta, rice, oats, barley, cornmeal, bulgar, and other plain grains the following made with milk or milk products, breads, rolls, biscuits, muffins, pancakes, sweet rolls, waffles, crackers, instant and dry cereals with added milk products, some packaged grain mixes, packaged macaroni mixes Meat and meat substitutes plain beef; lamb; veal; pork; wild game; poultry; fish; shellfish; eggs; kosher prepared meat products; peanut butter; peas, beans, or lentils (dried, canned or frozen); all nuts and seeds; tofu Fats & oils bacon, butter, margarine without milk derivatives (whey), salad dressing without cheese or milk, vegetable oils, olives, most non-dairy creamers, mayonnaise, gravy eggs, fish, meat, or poultry (breaded or creamed); luncheon meats; sausage; frankfurters; some brands of egg substitutes and powdered eggs cream, half & half, sour cream, cream cheese, chip dips, some types of margarine, salad dressing with cheese or milk, whipped toppings made without milk or milk products Sweets & desserts angel food cake, gelatin, fruit ice, fruit ice cream, ice milk, some brands of popsicles, fruit roll ups, hard candy, gum sherbet, soufflé, mousse, pudding, drops, jelly beans, licorice, fruit pie fillings custard, packaged dessert mixes, milk chocolate, toffee, caramel, butterscotch Beverages Postum, lactose-free nutritional supplements (Sustacal, Ensure, Nutren), vegetable juice, fruit juices and drinks, tea, carbonated beverages, beer, wine, distilled spirits (gin, rum, etc.), cocoa powder, most coffee Soups bouillon, broth, meat, or vegetable stock cream soup, canned and dehydrated soups; bisques and chowders made with soup mixes containing milk products water, soy milk, or 100% lactose-free milk Miscellaneous popcorn, plain pretzels, plain potato and corn tortilla chips, salsa, mustard, ketchup, pickles, uncreamed horseradish, relish, sauces made without milk or milk products, sugar, honey, jams and jellies, maple and corn syrup, molasses, herbs, spices, salt, pepper instant iced tea, instant coffee, Ovaltine, chocolate drink mixes, cordials, liqueurs, milk-based nutritional supplements (Carnation Instant Breakfast) cream or cheese sauces, ranch-style or cheese-flavored snack pretzels or chips, cheese curls, sugar substitutes with lactose added, medications and vitamin/mineral supplements with lactose added Sample Menu-Lactose Free Breakfast Lunch orange juice, calcium fortified 1/2 cup oatmeal 1 cup Italian bread 2 slices jelly 2 tsp margarine 2 tsp coffee 1 cup sugar 1 tsp nondairy creamer turkey 2 oz Italian bread 2 slices mayonnaise 1/2 Tbsp tossed green salad 1 cup oil & vinegar 2 tsp tomato 2 slices carrot 1 celery 1 stalk banana 1 lactose-free milk 1 cup Dinner roast beef 4 oz noodles 1/2 cup broccoli 1 cup Italian bread 1 slice margarine 2 tsp pear 1 tea 1 cup lemon 1 slice sugar 1 tsp Calories This Sample Diet Provides the Following 1800 Fat 48 gm Protein 93 gm Sodium 1700 mg Carbohydrates 261 gm Potassium 3533 mg This packet was prepared for you by Dr. Aaron J. Burrows (303) 320-1111