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Lactose-restricted diet Your doctor has prescribed a lactose-restricted diet. Please follow these guidelines as you plan your diet. If you have any questions, please call our nutrition clinic for help. If you have questions…. Please call our nutrition clinic at: 617- 667- 2565 What is lactose? Lactose is a natural sugar found in milk and in foods made from milk such as ice cream, yogurt, cheese, and butter. Many baked products and processed foods also contain lactose. Lactose is a so-called “complex sugar.” In order for it to be used by the body, it must be split into two “simple” sugars – glucose and galactose. An enzyme called lactase is needed for this breakdown. The lactase enzyme splits the lactose so that its sugars can be used by the body. What is lactose intolerance? Lactose intolerance is a condition in which there is problem digesting lactose in the diet. It occurs when there is not enough of the lactase enzyme to split all the lactose a person takes in. This leaves some of the lactose undigested. Undigested lactose draws fluid into the digestive tract. This extra fluid can cause diarrhea. In addition, bacteria that are normally present in the colon begin to use the undigested lactose as food, producing hydrogen gas as a by-product. This causes bloating and gas. A person is said to be lactose intolerant if nausea, abdominal cramping, bloating, gas, and/or diarrhea occur 30 minutes to two hours after consuming milk, milk products, or foods prepared with milk. What causes lactose intolerance? Lactose intolerance is caused by a deficiency of the lactase enzyme. There are three types of lactase deficiency that can cause lactose intolerance. Primary lactase deficiency The most common type is primary lactase deficiency. It is caused by a gradual decrease in lactase production after the age of two years. Members of certain ethnic groups are prone to this type of lactose intolerance. People who have primary lactase deficiency often have enough lactase during infancy and early childhood. But by adolescence, symptoms of lactose intolerance appear. By adulthood, at least ½ to ¾ of African and American blacks, as well as Arabs, Israelis, and Asians are lactase deficient. Among Caucasians of northern European ancestry, lactase deficiency is less frequent, occurring in only 5 to 20 % of young adults. 1 Secondary lactase deficiency Some diseases can cause damage to the lactase-producing cells in the intestines, causing a lactase deficiency. This is known as secondary lactase deficiency. Examples include celiac sprue and inflammatory bowel disease. In some cases, treating the underlying disease will result in an improvement of lactase production and normal lactose digestion. In other cases, symptoms of lactose intolerance remain indefinitely. Secondary lactase deficiency can also occur when the digestive tract has not been used for a long time. This sometimes occurs during prolonged or critical illness, when patients are given nutrition by vein instead of into the digestive tract. In most cases, this type of condition is temporary. Normal lactose digestion slowly returns after the person begins eating and drinking again. Congenital lactase deficiency A rare condition known as congenital lactase deficiency can cause lactose intolerance from birth. Babies born with this disorder have little or no ability to produce lactase. All lactose-containing foods must be eliminated from the diet. How is lactase deficiency diagnosed? Currently, two methods of diagnosing lactase deficiency are used: the hydrogen breath test and the lactose tolerance test. Hydrogen breath test The hydrogen breath test is the most common way to identify people who are lactase deficient. A person drinks a lactose solution, then breathes into a balloon. A special apparatus called a gas chromatograph measures the amount of hydrogen in the expired breath. A high level indicates lactase deficiency. Lactose tolerance test Another method of diagnosing lactase deficiency is the lactose tolerance test. A person drinks a lactose solution, and blood samples are taken at various intervals. If the digestion of lactose is normal, the lactase enzyme will begin to split the lactose into glucose and galactose shortly after it is consumed. The blood tests will show a rise in blood glucose. In lactase deficient individuals, the lactose is not digested, so the blood glucose does not increase. What is the treatment for lactose intolerance? Although lactose intolerance cannot be cured, most patients can learn to control their symptoms and maintain good nutrition. There are three aspects to most lactose intolerance treatment plans: 1. Control the amount of lactose in the diet. Not everyone with lactose intolerance is the same. You may be able to tolerate a certain amount of lactose in the diet, or to tolerate certain foods better than others. For a while, you will need to pay attention to what you are eating and how you feel. That 2 Sources of lactose: Remember, check food labels see if any of these ingredients appear. milk cheese yogurt ice cream butter margarine buttermilk (may cause fewer symptoms in some people) sweet acidophilus milk milk chocolate cold cuts hot dogs cream some sweeteners dried or powdered milk milk solids lactose whey curds caseinate lactoglobulin some vitamins or other medications, prescription and nonprescription – ask your pharmacist for further information will help you decide how much lactose your system can tolerate. As you are learning, remember: The main sources of lactose are listed in the box to the left. Be aware that prepared foods can also contain lactose. Read food labels carefully to see if milk, cheese, or other lactosecontaining ingredients have been added. In the most severe cases of lactose intolerance, such as during acute phases of Crohn's or celiac disease, patients usually cannot take in any lactose at all. In many cases, lactose foods may be slowly introduced later, when the acute phase of illness has passed. To find out what lactose foods your body can tolerate, start with small amounts of low-lactose foods. Aged cheeses, such as cheddar and Swiss, are very low in lactose. If you can eat these foods without feeling sick, try a small amount of a cultured milk product, such as yogurt. Eventually, you will learn what foods you can consume in small amounts, and what foods are best to leave out of your diet completely. Remember, whatever your own pattern turns out to be, keep servings of milk or milk products small. Many people are able to take in a small portion of a milk product, such as 1 oz. or ½ cup, with each meal and snack. This is one way to make sure you get the important nutritional benefits of dairy products without feeling sick. 2. Make sure you get enough calcium in your diet. Milk and milk products are a main source of calcium – an important nutrient in your diet. If you are taking in less milk, you will want to make sure to get enough calcium in 3 other ways. Foods high in calcium are listed in the box below. In some cases, your doctor or dietitian will recommend that you take a calcium supplement to make sure you are Lactose-free sources of calcium getting the calcium you need. 3. Use special products. A number of products are available that can help people with lactose intolerance. For example, Lactaid® milks and cheeses contain reduced lactose. Lactaid® 100 milk is 100% lactose free. Other varieties may have some lactose. broccoli collard greens kale turnip greens Chinese cabbage sardines with bones salmon with bones shrimp oysters blackstrap molasses tofu, processed with calcium salts Additional products, such as lactase enzyme tablets, can be taken with lactose-containing foods to help with digestion. Lactaid Ultra® is a convenient choice for many people. Have one to three tablets with your first bit of dairy food. The tablets work naturally to help your body digest the food. Soy and almond milk products, such as yogurt and cheese, are another option to explore. Sorbet is a delicious alternative to ice cream and does not contain lactose. In addition, Kosher foods that are labeled “pareve” do not contain milk or milk products. This material was prepared by clinicians from the department of nutrition services at Beth Israel Deaconess Medical Center. It is produced and distributed by The Beth Israel Deaconess Learning Center. ©2008 Beth Israel Deaconess Medical Center. All rights reserved. MC0876 0 4 Food choice guidelines for lactose intolerance Remember, no two people with lactose intolerance are the same. Experiment with small portions to find the food choices that are best for you. Milk and milk products Breads and cereals Potato and potato substitutes Foods allowed (low lactose or lactose-free) Foods to avoid, or to take in moderation (high lactose) Soybean and other lactose-free dietary supplements or formulas such as Boost; soy milk; non-dairy creamers made without lactose, such as Coffee Rich and Poly Rich; imitation cream cheese and other non-dairy imitation cheeses Milk and milk drinks in excess of the amount that you can tolerate, including whole, skim, dried and evaporated (except those treated with Lactaid); yogurt; cheeses; cottage cheese; ice cream; puddings; custards; junket; sherbet; supplements and formulas containing milk or lactose Breads made without milk, such as French or Italian bread; water bagels; pareve breads; matzohs; graham crackers; saltines; soda crackers; Syrian bread; most cooked and dry cereals made without lactose or milk solids Bread products made with milk or milk solids; prepared mixes; crackers made with butter; any baked product made with milk; muffins; biscuits; pancakes; waffles; donuts; sweet rolls; zweiback; cereal products made with milk solids or lactose, such as instant cream of wheat Potatoes; all enriched grain products, such as noodles, rice, spaghetti, macaroni, pasta or others prepared without milk or cheese Potato or potato substitutes prepared with milk or milk products (i.e. mashed potatoes) 5 Foods allowed (low lactose or lactose-free) Foods to avoid, or to take in moderation (high lactose) All cooked, canned, frozen, or fresh vegetables; all vegetable juices Vegetables prepared with milk, milk products, or cream sauces All fruits and fruit juices None! You may enjoy all the fruits and fruit juices you like. Meats and meat substitutes All meats, poultry, fish; kosher cold cuts; eggs; legumes; peanut butter; kosher frankfurters Meats, poultry, fish or meat substitutes prepared with cheese or cream sauces; breaded meat, fish, or poultry; cold cuts that are not kosher Fats/0ils Kosher pareve margarine (for example, Mother's Margarine); vegetable oils and shortening; salad dressings not containing lactose; pure mayonnaise; lard; bacon; nuts; olives; gravies prepared without milk or milk products Broth-based soups; any soup prepared without milk or milk products Cream; salad dressings made with milk or milk products; sour cream; butter; margarine made with milk solids; milk-based gravies Beverages (nondairy) Coffee, tea; decaffeinated coffee, soft drinks and carbonated beverages Cocoa and hot drink mixes; powdered fruit drink containing lactose Desserts/sweets Any made without milk or milk products, such as gelatin desserts, water ices, fruit pies, angel cake, fruit crisp; pudding and custard made with Lactaid milk All spices, herbs, and other condiments; sugar; honey; molasses; maple syrup; corn syrup; jelly; jam; hard candy; gum; gum drops; marshmallows; artificial extracts and flavorings Commercial desserts and baking mixes; desserts prepared with milk, milk products, or milk chocolate, such as ice cream, custard, puddings, junket, sherbet, or ice milk Chocolates or other candies that contain milk or lactose Vegetables and vegetable juices Fruits and fruit Juices Soups Miscellaneous All creamed soups; chowders; cheese soups 6 7