Diet Tips:Milk alternatives on a low FODMAP diet

By CK Yao (Accredited Practising Dietitian, PhD candidate)

The food industry has responded to consumer demand and now produces a large range of milks from plant sources, coconut, and almond.

In our latest Monash University Low FODMAP app update, we included plant-based milks that were tested in collaboration with the dietitians at King's College, London, UK.

Our tests revealed that the majority of European soy milk products were made from soy beans, whereas Australian soy milks were made either from soy beans or soy protein extract. Soy milk made from soy beans tends to be high in the FODMAP galacto-oligosaccharide (GOS). By contrast, soy milk made from soy protein extract tends to be low in FODMAPs as the carbohydrate component (GOS) is removed in processing .

If you can't find soy milk products made from soy protein extract, low FODMAP milk alternatives include:

•        Almond milk
•        Coconut UHT milk
•        Soy milk made from ‘hulled’ soy beans
•        Hemp Milk  (not available in Australia or NZ, but widely available in Europe and USA)
•        Coconut UHT milk  (small serves)
•        Soy milk made from hulled soy beans (small serves)

      →See the Monash App for serving sizes.

Nutrition tip: Whilst plant-based milks are good low FODMAP alternatives, they do not contain the natural benefits of lactose-free dairy products, including calcium, vitamin B12 and phosphorus. These nutrients are important for cognitive function and building strong, healthy bones and teeth.

If you have a dietary requirement for plant-based milks, ensure that the product you choose is calcium fortified (≥120mg/100ml). This will ensure that 1 x 250 ml glass of plant-based milk provides one serve of calcium (based on the Australian Healthy Eating guidelines).

Remember, a low FODMAP diet does not need to be a dairy free diet.

 

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:The low FODMAP diet in East and South East Asia

By Marina Iacovou (PhD Candidate and Accredited Practising Dietitian)

In October 2015, we published an article in the Journal of Neurogastroenterology and Motility, on how the low FODMAP diet can be applied to countries in East and South East Asia. There is growing interest in using food choice/dietary change to influence clinical outcomes in patients with irritable bowel syndrome across the globe, in particular the low FODMAP diet. This interest has also led us to testing international foods, sourced from other countries.
 

Major high FODMAP sources are frequently used in Asian cuisines, including: onion, garlic, shallots, legumes/pulses, and wheat-based products. Also many Asian countries are adopting some more Western dietary habits, such as the inclusion of lactose-containing milk and dairy products. Both of these factors are likely to be contributing the prevalence of IBS in Asia.

Traditional and commonly consumed dishes were considered in the article, for their FODMAP content - some of these include:

•         Korean dishes: Kimchiand Doenjang (fermented side dishes) and Mandu (Korean dumplings)
•         Japanese dishes: Gyozas(the equivalent to dumplings)
•         Thai dishes: Tom Yum Soup
•         Chinese and Hong Kong dishes: Man tou and Bao (wheat based buns), and red bean sweet soup and green (mung) bean soup, wontons and dim sum
•         Taiwanese dishes: street food called stinky tofu (yes that’s right, it’s not a typo) and youtiao (deep fried dough sticks made with wheat flour)
•         Vietnamese dishes: Hanh phu(fried shallots) and Nuoc mam cham(dipping fish sauce) and Pho bo tai nam(commonly known as Pho – a beef noodle soup)  

 

Although these dishes have not been tested for their FODMAP content as a complete meal, in their usual serving size, we have tested many of the ingredients found in the recipes. These ingredients are high in FODMAPS (onion, garlic, leek, shallots and mung beans), and therefore, the likely FODMAP content of these traditional dishes may be moderate-high FODMAP. For this reason, dietary approach, using the low FODMAP diet, holds great promise in treating IBS patients in East and Southeast Asia.

 

Common Asian ingredients that we have tested are also listed in the article with their corresponding FODMAP rating (low, moderate or high).There is no reason to miss out on these delicious Asian cuisines. Whether you are eating out, travelling, or cooking Asian dishes at home - there is always a low-moderate FODMAP option. 

You can find more tips on dining out Asian here.

Marina Iacovou, Victoria Tan, Jane G Muir, and Peter R Gibson – The Low FODMAP Diet and its Application in East and Southeast Asia; Journal of Neurogastroenterology and Motility, Volume 21 No. 4 October, 2015.

 

Diet Tips:A1 vs A2 milk – What’s the big deal?

By Shirley Webber

With the milk industry in the limelight at the moment many people are asking questions about what we are actually consuming. One questions that we often get is “what is the difference between A1 and A2 milk?”

The Monash University team are conducting a study at the moment looking into the effects of these two different milks and what effects A1 vs A2 milks may have on gut transit time, behavioural/psychological health and gastrointestinal symptoms.

So what’s the difference?

A1 and A2 are two proteins that are part of the casein proteins found in dairy products and we refer to these as beta-casein A1 and beta-casein A2.

The image below shows the composition of 1 cup of milk:

 

As you can see from the image above one cup of milk contains water, lactose, fat, minerals and protein. Within the protein we find casein and whey. There are various types of casein with beta-casein making up 2-3 grams of milk solids.

These beta-caseins are produced by different types of cows.

Interesting fact: beta-casein A2 is the original beta-casein produced in cow’s milk. A natural mutation over a number of centuries occurred where cattle began to also produce A1 beta-casein, affecting mainly Holstein cows (cattle from European origin).

The image below show the types of cattle used in milking and the A1 vs A2 beta-caseins that they produce.

Holstein cow’s milk =  1:1 A1 & A2 milk beta-casein	Guernsey or Jersey cow’s milk = high % in beta-casein A2	Goats, water buffalo, sheep, cattle from Asian origin and human breast milk = proteins similar to A2

Let’s get into a little more science. A1 and A2 beta casein proteins are made up of 209 amino acid chains. There is only one amino acid difference between the A1 amino acid strand compared to the A2 amino acid strand. This very small structural difference results in a big difference in the way the protein breaks down and is digested in our gut.

When the A1 amino acid chain breaks down it produces a peptide called BCM-7. BCM-7 (beta-casein morphin) is an opioid-like compound. In the human body, BCM-7 has been shown to slow down gut transit time (slows transport of food / digestion throughout the body) therefore can cause a change in bowel function, influence gut bacteria and inflammation in the gut. It is thought these changes can mean some individuals poorly tolerate milk.

There have been many animal studies conducted in this area but more investigation needs to be conducted to investigate what effects these different milk proteins has in humans.

The major point to make is that BCM-7 production does not occur after we consume the A2 beta-casein. So choosing A2 beta casein rich milk products may help some individuals.

For our research investigating the different effects of A1 vs A2 beta-casein milk we are looking for healthy and IBS constipation predominant volunteers to help shine some light onto this topic.

Healthy volunteers:	IBS
Age between 18 – 60 years      Live in Melbourne      Have no known gastrointestinal conditions	Age between 18 – 60 years      Living in Melbourne      Have non-diarrhoea predominant Irritable Bowel Syndrome (IBS)      Do not have any other gastrointestinal disease (eg. Coeliac disease, Crohns disease, Ulcerative Colitis)

What do you get?

We will be providing our participants with all milk that is to be consumed during two intervention periods of this study (A1/A1 and A2/A2 milks) as well as providing our participants with cheese. You get to have full access to a dietitian to assist you throughout the study and a free consultation at the conclusion of your participation.

What are we asking of participants?

To follow a dairy free diet with the exception of the milk and cheese that we will be providing. Be able to attend 9 consultations at the Alfred Hospital over 12 weeks of doing this study. Also be willing to give blood and small faecal samples.

Find out more about the study here.