Diet Tips:What is lactose intolerance?

By Lyndal McNamara (APD)

As a dietitian, I often see patients who have just been diagnosed with lactose intolerance and understandably assume that this means they need to avoid all dairy products. You will be relieved to know that this is certainly not the case! In fact, most dairy products can still be enjoyed on a low lactose diet. But first, what exactly is lactose and what does a diagnosis of lactose intolerance really mean in terms of diet?  

What is lactose and what is lactose intolerance?

Lactose is a type of sugar found most commonly in milk and other dairy products. When foods/drinks containing lactose are consumed, the body needs the help of an enzyme named lactaseto break down the lactose sugar into smaller pieces for digestion and absorption (see picture below). Individuals who have lactose intolerance make less lactase enzyme, so may find it difficult to digest lactose properly when they consume a large amount of a lactose-containing food/drink. This can ultimately result in unpleasant symptoms such as bloating, wind, stomach cramps and diarrhoea.

What is the difference between lactose intolerance and an allergy to dairy?

Lactose intolerance should not be confused with a dairy allergy. A true food allergy is an adverse reaction to a food that involves the body’s immune system and can result in severe symptoms that can even be life threatening. Someone with a dairy allergy may experience severe symptoms even if they consume minute quantities of a dairy product; it is therefore usually essential that they strictly avoid all dairy. Lactose intolerance is different in that consumption of small to even moderate amounts of lactose may not actually trigger any symptoms. Despite the symptoms of lactose intolerance being unpleasant, exposure to too much lactose will not result in life threatening symptoms. Strict avoidance of lactose is therefore unnecessary. 

How much lactose can I have before experiencing symptoms?

This will vary between individuals, however research suggests that most people with lactose intolerance can tolerate 12-15g of lactose per day (equivalent to up to 250ml of regular milk) and possibly even more if lactose consumption is spread throughout the day rather than in a single sitting. (1-3)

Is there anything I can take/do to improve my tolerance to lactose?

Lactase enzyme products (tablets or drops) are available at most pharmacies and may assist with lactose digestion when taken with a lactose containing food. Consuming lactose containing foods together with other foods may also improve tolerance.(3)

How much lactose do dairy products actually contain?

As you can see from the table below, this is very variable! Whilst regular milk is high in lactose, many common cheeses such as cheddar, feta and even soft cheeses like brie and camembert contain virtually no lactose in a typical serve. Whilst yoghurt is listed as a high lactose food, there are many varieties available that are low lactose or even lactose free that are usually well tolerated. Try yoghurts that have added live bacterial cultures, as these are usually easier to digest. Lactose free varieties of many dairy products including cow’s milk, cream, sour cream and cream cheese are also now readily available. These products are identical to the regular variety, they simply have some lactase enzyme added to them, and so the lactose has already been digested for you!

Lactose content of common dairy foods

Dairy product	Lactose content /serve	Serving size	Lactose classification/serve
Full cream milk	15.75g	250ml	High
Low-fat milk	15.25g	250ml	High
Skim milk	12.5g	250ml	High
Natural Yoghurt	8.5g*	170g	High
Regular flavoured yoghurt	5.8g*	170g	High
Thickened Cream	3.75g	125ml	Moderate
Sour cream	3.13g	125ml	Moderate
Cream cheese	2.0g	80g	Moderate
Ricotta Cheese	1.6g	80g	Moderate
Cottage cheese	0.7g	36g	Low
Feta Cheese	0.13g	125g	Low
Cheddar (tasty) Cheese	0.04g	40g or 2 slices	Low
Camembert Cheese	0.04g	40g	Low
Brie Cheese	0.04g	40g	Low

 

*The lactose content of yoghurt varies significantly between brands and this value reflects the average lactose content only.

Data source: NUTTAB 2010 database

Will I miss out on any essential nutrients if I follow a lactose free diet?

Many dairy foods containing lactose are important sources of calcium in the diet, so if you avoid dairy products for any reason, it is important that they are replaced with suitable calcium rich alternatives. The range of lactose free dairy products available on the market mean that you can consume a low lactose, calcium rich diet very easily. Choose lactose free milk, probiotic yoghurts or lactose free yoghurts and choose naturally low lactose cheeses from the list above. If you do this you will still get enough calcium in your diet. Alternatively, if you choose non-dairy, lactose free milks including those made from soy, rice, nuts such as almonds and even coconut, it is important to ensure that you buy a brand that contains added calcium, as these products do not naturally contain much calcium. Ideally look for a variety that has 200-300mg of calcium per 250ml serve. Remember to always speak to your dietitian before making major changes to your usual diet to ensure you will not be missing out on any important nutrients!

References:

1.            Savaiano DA, Boushey CJ, McCabe GP. Lactose intolerance symptoms assessed by meta-analysis: a grain of truth that leads to exaggeration. The Journal of nutrition. 2006;136(4):1107-13.

2.            Suarez FL, Savaiano D, Arbisi P, Levitt MD. Tolerance to the daily ingestion of two cups of milk by individuals claiming lactose intolerance. The American journal of clinical nutrition. 1997;65(5):1502-6.

3.            Shaukat A, Levitt MD, Taylor BC, MacDonald R, Shamliyan TA, Kane RL, et al. Systematic Review: Effective Management Strategies for Lactose Intolerance. Annals of Internal Medicine. 2010;152(12):797-803.

Diet Tips:NEW PUBLICATION ALERT: Consistent prebiotic effect on gut microbiota with altered FODMAP intake in patients with Crohn’s disease: a randomised, controlled cross-over trial of well-defined diets

By CK Yao (Accredited Practising Dietitian, PhD candidate)

Research by our team has recently identified that a reduction in FODMAP intake in individuals with Crohn’s disease who were in remission produced significant changes in the gut bacteria, particularly selected species with beneficial roles in gut health.

The effectiveness of a low FODMAP diet therapy in inflammatory bowel disease (IBD) had only been explored in a group of patients with IBS-like symptoms and inactive IBD. Considerable improvement in symptoms occurred in > 50% patients after 6 weeks of the diet. However, it is not known whether a low FODMAP diet there may be potential negative changes as seen in a recent study in IBS. An ‘imbalance’ in gut bacteria may already be occurring in some individuals with inflammatory bowel disease.

We recently studied the habitual FODMAP intake and gut bacteria of 8 participants with stable Crohn’s disease and the effects of altering their diets. They were fed diets containing either low FODMAP or a ‘typical Australian’ diet (see sample meal plan) for 3 weeks, followed by a 3-week break before crossing over to the other diet. Daily gut symptoms were measured as well as changes in stool bacteria during both dietary periods.

Sample meal plan	Typical Australian diet	Low FODMAP
Breakfast	Honey quick oats or wheat flakes with dried fruit cereal with ½ cup lactose-free milk Packaged peaches	Brown sugar and cinnamon quick oats or rice bubbles with ½ cup lactose-free milk 2 kiwi fruit
Morning tea	Lactose-free yoghurt 2 rye vita crackers with cheese	Lactose-free yoghurt 2 rice cakes with cheese
Lunch	Wheat sandwich Vegetable fritata Apple juice	Spelt sandwich Low FODMAP vegetable frittata Cordial
Afternoon tea	Pear 2 chocolate biscuits	Banana 2 gluten-free chocolate biscuits
Dinner	Braised lamb shanks with vegetables Salmon and vegetable couscous	Braised lamb shanks with low FODMAP vegetables Salmon with low FODMAP vegetables and quinoa
Supper	Apple sorbet	Raspberry sorbet

Study findings:

•       When on a typical Australian diet, there was a significant increase in beneficial bacteria associated with favourable health outcomes compared to a low FODMAP diet, consistent with a ‘prebiotic’ effect.
•       However, overall symptoms, abdominal pain, bloating and excess flatulence were almost doubled than symptoms on a low FODMAP diet.
• Interestingly, the habitual FODMAP intake in participants with Crohn’s disease was low, similar to levels on a low FODMAP diet. Not surprisingly, the low FODMAP diet did not improve the severity of gut symptoms compared to symptoms on their habitual diet.  

Take home messages:  A high FODMAP diet may produce beneficial prebiotic effects for gut health in Crohn’s disease. It suggests that trialling this diet during periods of active inflammation may not necessarily be ideal for the large bowel.  On the contrary, a low FODMAP diet may be beneficial in reducing residual IBS-like symptoms in individuals with inactive Crohn’s disease.  A specialist gastrointestinal dietitian will be able to advise on finding a balance between consuming adequate prebiotic FODMAPs and maintaining good symptom control.

Read the full article here.

 

Diet Tips:Timing of symptoms

By Dr Jaci Barrett (APD)

IBS is very common, but the symptoms are varied – constipation, diarrhoea, alternating bowel habit, bloating, abdominal distension, abdominal pain, excessive gas and borborygmi (intestinal noises). Some people experience all of these symptoms at some time or another, while others have more specific symptoms, for example where bloating is the major symptom. When symptoms are experienced, people often consider what they most recently ate to determine the trigger food. Were there FODMAPs in that meal? What other foods could have contributed? Many times we hear patients state that within minutes of food hitting their stomach, they are on the toilet with urgency, diarrhoea and abdominal cramps. Is this possible?

Let’s consider the anatomy of the human gastrointestinal system:

Bowel transit studies indicate that in healthy individuals, the time taken for a substance to move from the mouth to the anus is somewhere between 12 and 48 hours.

The small intestine is particularly long – 6 metres in fact. The large intestine is ~1.5 metres long. So given the time it takes for food to move through the gut, symptoms experienced immediately after swallowing a suspect food cannot be attributed to the fermentation of FODMAPs ….

So how does this immediate symptom induction occur in some people?

The most likely explanation is the impact of hormones and nerve regulators that are triggered when we eat. For instance, when food enters the stomach, hormones such as cholecystokinin and secretin are released. These hormones stimulate the production of enzymes that aide digestion. In addition, when the stomach is stretched by the entry of food, nerves in the digestive system are stimulated. These nerves stimulate the movement of intestinal muscles which push food and digestive juices through the gut.

Because digestion takes many hours to days, the intestinal tract is always full of digestive contents from previous meals, and as a meal is consumed, these existing intestinal contents are moved through the intestines. So if the existing intestinal contents contain FODMAPs or other problem food components, symptoms may be experienced upon eating that have nothing to do with the current meal and everything to do with the previous meal/s. These delayed symptoms can be confusing and may have you pinpointing the wrong trigger food.

So what is the take home message? Consider previous meals you have eaten and whether they could have played a role, or whether there are other complicating factors such as stress that has had an impact on bowel function. If you are still confused and unable to work out what is causing your symptoms, keep a list of foods you have eaten over the 48 hours prior to experiencing symptoms and show this to your dietitian to utilise his/her food detective expertise!

 

 

Diet Tips:Alleviating symptoms

By Shirley Webber

We’ve all eaten something that just doesn’t sit well and resulted in symptoms. Most frequently when we are eating out and have had less control over what we are eating. Following a low FODMAP diet can help manage symptoms but what can you do when you’re in the middle of experiencing those symptoms?

Symptoms vary from one person to the next including bloating, abdominal pain, distention, constipation, diarrhea, altered bowl habits, excessive gas and intestinal noises, or any combination of these. Each symptoms has its own management strategy.

We are going to bring you some tips to help alleviate symptoms over the coming weeks, including ideas to help with acute symptoms which occur quickly after you have eaten a trigger food, as well as ideas to help prevent symptoms from occurring in the future.

We will start the first blog of the series with some information for those that suffer constipation as a major symptom.

Constipation can be alleviated by:

• Ensuring that your diet includes foods rich in insoluble and soluble fibres. Insoluble fibre gives bulk to your stool and soluble fibre forms a gel in the gut that helps stools to move through the gastrointestinal tract. Introducing these fibres gradually will help to avoid exacerbating your symptoms.
• If constipation is severe and laxative medication is required, take this as prescribed by your doctor.
• Drink plenty of water throughout the day.
• Exercise regularly to help to get things moving. Try going for a walk, taking the stairs instead of the lift or escalator, join a yoga or Pilates class or go for a jog. It doesn’t have to be intense exercise but any little bit of physical activity will help.
• If you have the urge to open your bowels, GO - even if it means using a public toilet or the toilet at work or school. You may also need to make time to open your bowels by getting up a little earlier in the morning and leaving time for a drink and breakfast.
• Fibre supplements may be recommended by health professionals for those struggling with constipation. Use these as prescribed.

Please see the blog attached for more details:
http://fodmapmonash.blogspot.com.au/2015/12/ibs-constipation.html