The Lactose Intolerance Clearinghouse Has Moved.

My old website can be found at www.stevecarper.com/li I am no longer updating the site, so there will be dead links. The static information provided by me is still sound.

For quick offline reference, you can purchase Planet Lactose: The Best of the Blog as an ebook on Smashwords.com or Amazon.com or BarnesandNoble.com or a whole lot of other places that Smashwords is suppose to distribute the book to. Almost 100,000 words on LI, allergies, milk products, milk-free products, and the genetics of intolerance, along with large helpings of the weirdness that is the Net.

I suffer the universal malady of spam and adbots, so I moderate comments here. That may mean you'll see a long lag before I remember to check the site and approve them. Despite the gap, you'll always get your say. I read every single one, and every legitimate one gets posted.


Wednesday, March 31, 2010

Kids May Need Two EpiPens

A major study just out in the journal Pediatrics (Rudders, Susan Pediatrics, April 2010; vol 125: pp: e711-e718) has been making headlines in newspapers all over the country. Dr. Rudders' teams looked at 1255 children who were admitted to emergency rooms at two large Boston hospitals between 2001 and 2006. All the children were under 18, but the average age was closer to six. Just over half (52%) of the children had a true anaphylactic reaction. Of these 44% received epinephrine and 12% of these needed two shots. Some of these shots were given at home, some at the hospital.

That's an awful lot of anaphylactic children who received no epinephrine at all. A Reuters article summed up the study's findings of the failings.

What's troubling, the researchers say, is that half of the children with food-induced anaphylactic reactions did not get epinephrine either before getting to the hospital or while at the hospital. At the hospital, the children received antihistamines, steroids, intravenous fluids and inhaled medicines more often than epinephrine, "despite the lack of evidence" for their usefulness as a first-line treatment, the authors note.

Additionally, fewer than half of the children with food-related allergic reactions left the hospital with a prescription for self-injectable epinephrine and only 22 percent were advised to see an allergist.

Clearly, food-related anaphylaxis "continues to be under-recognized and inadequately treated," Rudders and colleagues warn. Estimates suggest that approximately 150 to 200 people die each year from food-related anaphylactic reactions, and delayed or lack of administration of epinephrine is often to blame.


UPI had a further important quote.
"Until we're able to clearly define the risk factors for the most severe reactions, the safest thing may be to have all children at risk for food-related anaphylaxis carry two doses of epinephrine," first author Dr. Susan Rudder says in a statement.

To offset costs, Rudders suggests, school nurses carry un-assigned extra doses of injectable epinephrine for the children who need them.

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Tuesday, March 30, 2010

Draw A Soymilk Sun, Win Your School $1000


Over at PerishableFoods.com I found a press release that turns out to be sunnier than most.

Stremicks Heritage Foods is relaunching it’s 8th continent Soymilk brand. The re-launch includes the debut of a new carton packing in the spring. To celebrate the event, the company is inviting children and their families to submit their artwork to be considered for the brand’s new packaging. All entries must be received by 11:59 pm ET June 12, 2010 to be considered in the contest. To submit your artwork for the competition, visit www.8thcontinent.com/. 100 winners will be recognized and awarded with $1,000 in art supplies. All submissions will be featured on the company’s website.

Stremicks Heritage Foods™ (Heritage), founded in 1990, manufactures, sells and distributes value-added, specialty beverage products on a regional and national scale. Headquartered in Santa Ana, Calif., the company operates in Santa Ana, Riverside and Ontario, Calif.; Cedar City, Utah; Joplin, Missouri and Mexicali, Mexico. Heritage owns, licenses and co-packs well recognized brands such as Heritage Organic Milk, Heritage Organic Milk with Omega-3 DHA, 8th Continent Soymilk, Kerns Beverages, Heritage Disney Toy Story Chocolate Milk, Lactaid Refrigerated, Rice Dream, Soy Dream, Soup Broths, Protein Drinks & Sports Nutrition Beverages.

If you visit the site, you'll have to temporarily allow pop-ups. But that takes you to a page on which your children can paint right on screen - with a mouse, of course - to create a sun logo for the new packaging. That painting can be uploaded directly from that page as well. Winning may allow a school to receive up to $1000 for its art program. Be sure to click on the Terms and Condition link at the bottom of the page for the full, long, list of rules and caveats.

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Sunday, March 28, 2010

Some Vegan-Friendly Foods

Geri Maria Harris wrote about the Top 5 Vegan-Friendly Foods Even Carnivores Will Love for a blog in the Houston Press.

We all know that when a blogger talks about the Top 5 anything it really means five things scraped together to fill up space rather than "Top" so I hope none of you are taking that headline literally. That's why I titled this post "Some Vegan-Friendly Foods." Wow. That's exciting, isn't it? And that's why bloggers lie to you on a regular basis. Along with everybody else who has ever written a headline. Truth doesn't jump off the screen and grab your eyeballs. Pity.

Three of the five seem to be worth your time and attention regardless. I've mentioned two of the firms before but one is new and it's nice to have them together like this. Besides, I'll give you links directly to their sites so you can explore them further.

Amy's Roasted Vegetable Pizza


Pizza without cheese? Doesn't sound too great, we know. But somehow, it is! Amy's starts this scrumptious pie off with a hearty whole-grain rice crust, then tops it off with organic olive oil, tomatoes, and a medley of other veggies that actually taste good. It sounds weird, but it works. We always have to end up sharing at least half of this single-serving entrée.

Uncle Eddie's Vegan: Oatmeal and Chocolate-Chip Cookies

We know there are many amazing vegan cookies out there, but Uncle Eddie's are our personal favorite. They have several flavors to choose from, but we like the substantive texture of the oatmeal blended seamlessly with the creaminess of the chocolate. You can actually pronounce every ingredient listed on the package, which is a plus. We brought some home yesterday and after having a few non-vegan friends over, the bag was totally empty. Not even a crumb.

Rice Dream Chocolate Frozen Pie


All right, so maybe we have a sweet tooth right now, but these things are truly decadent. A heavenly thick layer of creamy "rice cream" is sinfully sandwiched between two oatmeal cookies and covered with chocolate. We tried our first one yesterday while babysitting a niece, and let's just say we were lucky she didn't go after ours once she had finished her own. It was definitely family feud-inducing stuff. We can't wait until it gets even hotter outside and we have an actual excuse to indulge in this delightfully icy extravagance.

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Saturday, March 27, 2010

Substituting for Evaporated and Condensed Milk

I received this question recently:

Are there any canned lactose free evaporated or condensed milk products? If not, do you have a recipe on how to make lactose free evaporated and condensed milk?

The answer, sadly, is that there aren't any lactose-free evaporated or condensed milk products on the market. (Lactaid did a tryout of one in Puerto Rico, but has no plans to take it further.) Creative cooks will have to devise substitutes. No one-size-fits-all answer comes to mind, though. You'll definitely need to think about what you're cooking and what the role of the milk is in it.

First, what are evaporated and condensed milks? A good answer can be found at the Eating with Food Allergies site.
Evaporated Milk
Evaporated milk is just concentrated milk (with about 60% of the water removed). For an easy substitute, use Vance's Foods DariFree Original Powder Gluten-Free Beverage. Rather than mixing it as milk, mix 1/2 c. of the powder with 1 c. of hot water. I used this substitute in this Dairy Free Fudge recipe.

Sweetened Condensed Milk
Sweetened condensed milk is just evaporated milk with sugar added. To make your own dairy free version, make 1 c. of evaporated milk (recipe above) and, over medium heat, dissolve 1-1/2 c. of granulated sugar in the mixture.


Vance's Foods DariFree is a potato starch-based nondairy milk substitute that is useful is many alternative recipes.

That's just the starting point. When people look for an evaporated milk substitute, pumpkin pie is often the target. I've given a couple of different possibilities for this in previous posts. One answer is tofu, as in Use Tofu to Substitute for Evaporated Milk. Plain soy milk will work if you boil it down to about two-thirds its original liquid content. You can also try just cooking a pie five to ten minutes longer to firm it better without boiling down the soy milk.

If you're looking for a generic substitute to use in many possible recipes, GoDairyFree has a maze of links that lead you to a variety of suggestions, from coconut milk to soy or rice milks.

And another range of possibilities emerge on this page at Celiac.com with plenty of cooks sharing their personal secrets.

You will have to do some experimenting to see which substitute works best with the particular dish or recipe you want to try. No easy answers, but a wealth of advice.

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Friday, March 26, 2010

Report from the LI Conference, part 17: Question 2 Summary

The Draft Report summarized the presentations that looked at Question 2 (Weaver; Heaney; and Wilt) as follows:

2. What are the health outcomes of dairy exclusion diets?

The health outcomes of dairy exclusion diets depend on whether other sources of nutrients, such as calcium and vitamin D, occur in the diet in sufficient quantities to replace dairy products as a source of these nutrients, and to what extent other components of milk are beneficial.

Calcium is necessary for normal growth and bone development as well as subsequent maintenance of bone density. The strongest argument for promotion of dairy ingestion is the beneficial effect of calcium (and fortified vitamin D in milk) on growth and development of the skeleton. Calcium is necessary for adequate bone accretion and optimal peak bone mass, which is a major determinant of risk for osteoporosis and fragility fractures later in adult life. Evidence suggests that certain age groups, such as children and teenagers, may be at increased risk for deficient bone acquisition if their diets are deficient in calcium or vitamin D. There is weak evidence that children with diets deficient in calcium have increased fracture rates. The maximal accumulation of bone mineral, and therefore the maximal calcium requirement, occurs during puberty. Although studies indicate that young children who drink milk are likely to meet or exceed the adequate intake for calcium, teenagers, as a group, tend not to take in enough calcium to meet recommended needs. This is exacerbated by dairy avoidance in individuals who consider themselves to be lactose intolerant, regardless of whether they have undergone objective testing for lactose intolerance.

Studies have demonstrated that the presence of lactose does not necessarily affect the efficiency of calcium absorption across the intestine, and that lactase nonpersisters do not have significant impairment in calcium absorption. Thus, the limiting factor in achieving optimal peak bone mass in young individuals is the intake of calcium. Similarly, in older individuals, low calcium intake rather than deficient absorption appears to be a major factor contributing to loss of bone mass. Replacement of calcium using supplements or dairy products slows the rate of bone loss in older people, possibly as a result of an overall decrease in bone turnover. Across the age spectrum, the factor limiting adequate calcium accrual in many individuals appears to be dairy avoidance.

Dairy exclusion diets may exacerbate the risk for osteoporosis for those already at greatest risk. These include women throughout the life cycle and certain racial/ethnic groups. Low intake of dairy products may place African Americans and others at risk for deficiencies of other necessary nutrients for bone health such as vitamin D, in addition to low calcium intake. Individuals with diseases that result in decreased calcium absorption due to intestinal inflammation (inflammatory bowel disease) or that require the use of corticosteroids (which in themselves directly reduce bone mass) have increased risk of osteoporosis.

Dairy exclusion diets may decrease gastrointestinal symptoms (bloating, cramps, flatus, and diarrhea) in symptomatic individuals who have lactose malabsorption or lactose intolerance. The degree of relief is likely related to the level of expression of lactase and the quantity of lactose ingested. People who remain symptomatic on a dairy exclusion diet may have other causes for their gastrointestinal symptoms, such as irritable bowel syndrome, celiac disease, inflammatory bowel disease, or small bowel bacterial overgrowth.

Dairy exclusion diets may affect other health outcomes. In several studies, individuals taking calcium supplements or increased dairy intake have decreased blood pressure. Calcium supplementation has been suggested to improve cardiac and vascular smooth muscle contractility; however, additional research is needed to clarify whether this has a significant impact on cardiovascular risk. Calcium ingestion has been associated with decreased risk of development of adenomatous colon polyps; it is not known whether this translates into decreased rates of colon cancer. One area of recent interest is the effect of lactose ingestion on colonic bacterial populations, as this may increase production of fatty acids such as butyrate, which may promote mucosal growth and reduce inflammation.

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Thursday, March 25, 2010

Report from the LI Conference, part 16

You want embarrassing?

Say you have a major federal agency, one that has responsibilities for a major, crucial, fraction of the nation's wellbeing. Call it, say, the National Institutes of Health. Make them responsible for the program of a major scientific get-together, say the state-of-the-science conference on Lactose Intolerance. And give that agency the very simple, basic responsibility of making the individual segments of that conference program accessible on the Internet, say, by posting links to each presentation and abstract. You do that, as everyone who has any knowledge of the Internet knows, by taking the URL and adding a # plus the name of an internal link.

So the URL for a link to, say, Evidence-based Practice Center Presentation II:
The Bone Health Outcomes of Dairy-Exclusion Diets by Timothy J. Wilt would read something like this:

http:// consensus.nih.gov/2010/lactoseabstracts.htm #Wilt

Simple enough.

Unless, that is, said Timothy J. Wilt, M.D., M.P.H. is the author of two different presentations. In which case, a URL that reads:

http:// consensus.nih.gov/2010/lactoseabstracts.htm #Wilt

takes you to the first of the two. And never the second. So I can't give you a direct link to the abstract of Evidence-based Practice Center Presentation II:
The Bone Health Outcomes of Dairy-Exclusion Diets because the boneheads at the NIH didn't think to make the link read #Wilt2.

Programming, even HTML-markup, is all details. Mistakes and typos are all too easy to make. But somebody has to click on all the links to make sure they work!

Anyway, for all the info about Dr. Wilt and his co-authors, see the entry I posted about part I of their multi-part presentation.

This particular presentation looked again at actual consumption of nutrients among those who had dairy and those who didn't. What happens with those who don't eat or drink dairy? They don't get enough calcium.

Vegan children consumed only 47% of the RDA for calcium. Vegan women got even less, a mere 30%.

The numbers were extremely similar for LI children (45%) and LI women (37%). LI, lactose intolerance, is being defined here as anyone who claimed symptoms from dairy. Those who tested as having a lactase deficiency, technically a somewhat different group, had a somewhat but not terribly different pattern, 44% for children, 50% for women. (Why no results for men? Apparently none of the 52 studies they summarized looked specifically at males apart from other groups.)

Does this lack of calcium make any real different for bones? The evidence there was thoroughly mixed. Some studies found no differences at all, but many did show increases for bone problems of all sorts for people who avoided dairy.

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Wednesday, March 24, 2010

Report from the LI Conference, part 15

Scientists are nothing is not methodical. After examining the consequences of dairy avoidance in children, you couldn't have found a sports book in all Las Vegas that would be willing to take money against what the next panel would be.

Consequences of Excluding Dairy or of Avoiding Milk in Adults
Robert P. Heaney, M.D., FACP, FACN
John A. Creighton University Professor
Osteoporosis Research Center
Professor of Medicine
School of Medicine
Creighton University

To no one's surprise, Dr. Heaney found that adults who think they have lactose intolerance tend to avoid dairy. And in fact, studies have found anywhere from 33% to 80% lower calcium intake in lactose intolerant populations.

Part of his talk did differ from expectations. In what should also be to no one's surprise, taking a properly close look at the nuances give a picture of reality at odds with conventional wisdom.

But it is an oversimplification to focus exclusively on single nutrients, even calcium. Nutrients are not drugs, and they do not act in a vacuum. Rather, like the instruments in a symphony orchestra, they produce their effects in concert with one another. A striking example of this mutual dependence is seen in the interaction of calcium and protein in the diet. Until recently, high protein intakes were considered to be potentially harmful for bone because of their effect on urinary calcium excretion. Increased calciuria was clearly demonstrated for protein and for pure amino acids, whether taken orally or intravenously. However, when protein was fed as a food, strangely there was no effect on calcium balance. More recently, it has become clear that calcium and protein, rather than antagonists, are actually synergistic in their skeletal effects. In postmenopausal women with low protein intakes, increasing calcium intake can slow bone loss, but not much more. By contrast, with high protein intakes, added calcium leads to actual bone gain. This is an important consideration in our context because individuals with low dairy intakes are missing not only the calcium but also a rich source of dietary protein, which is as necessary for bone rebuilding as is the calcium that is the more obvious component of bony material.

In brief, dairy supplies a broad spectrum of nutrients that work together better than gaining them individually or from foods less gifted. Even calcium-fortified orange juice isn't anywhere as good a source as dairy.

And here's a tidbit that will infuriate those who cherry-pick the medical journals for anti-milk reports.
While the focus of this session is predominantly on skeletal effects, it should be stressed that inadequate dairy intake has multiple other consequences as well, including increased risk of metabolic syndrome, hypertension, preeclampsia, obesity, and certain forms of cancer, particularly colon cancer. Thus milk avoidance is, for most adults, a risky behavior.

Reality is a harsh mistress.

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Tuesday, March 23, 2010

Report from the LI Conference, part 14

For the next three posts, we'll be in Section 2 of NIH state-of-the-state presentations on Lactose Intolerance.

What are the health outcomes of dairy exclusion diets?

Consequences of Excluding Dairy, Milk Avoiders, Calcium Requirements in Children
Connie M. Weaver, Ph.D.
Distinct Professor and Head
College of Consumer and Family Sciences
Department of Foods and Nutrition
Purdue University

Although it is perfectly true that a totally adequate intake of nutrients can be achieved without consuming any dairy products, the reality is that Americans as a whole don't follow anything like that diet. They don't come close to getting sufficient nutrients even with dairy. The numbers are scary.

The role of milk products in meeting three nutrients for various age groups is illustrated in Table 1.




Most food guidance patterns recommend 3 cups of low-fat dairy products daily. The table contrasts the proportion of individuals meeting the dairy recommendations with those receiving less than one serving of dairy products as assessed from data from the 1999–2004 National Health and Nutrition Examination Survey (NHANES). The best and most economical source of the limiting nutrients is dairy. Supplements typically do not fill the gap of all these nutrients for those who do not consume recommended intakes of dairy products. Using NHANES 2001–2002 data, Gao et al. determined that it is impossible to meet calcium recommendations while meeting other nutrient recommendations with a dairy-free diet within the current U.S. dietary pattern. Using the 1999–2004 NHANES data, Nicklas et al. determined that < 3% of the U.S. population met potassium recommendations and 55% did not even meet their Estimated Average Requirements for magnesium.


Bone mass growth comes during adolescence, with 95% of adult peak occurring by age 16. Getting proper nutrients in childhood in critical. Dairy drinkers have a real advantage in driving those numbers up to and past the critical requirements. Here's a table of what the bone-related nutrient requirements are for those under 18.

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Monday, March 22, 2010

Planet Lactose: The Best of the Blog

Long delayed, the announcement of my book finally appeared locally.

Planet Lactose was today's selection in the Rochester Democrat & Chronicle's Spotlight on Authors: Rochester Authors column.


Planet Lactose: The Best from the Planet Lactose Blog by Steve Carper (Planet Lactose Publishing, $16). This book distills three years of the author's blog, which focuses on avoiding dairy products for those who are lactose intolerant, have milk allergies, are vegan, or want to keep kosher. Carper, also author of Milk is not for Every Body, has spent 30 years exploring dairy-free living. Learn more at planetlactose.blogspot.com. Carper lives in Rochester.


You can purchase copies of the book by going to this page.

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Sunday, March 21, 2010

Report from the LI Conference, part 13a: Question 1 Summary

The Draft Report summarized the presentations that looked at Question 1 (Tishkoff; Wooten; Wood; and Wilt) as follows:

1. What Is the Prevalence of Lactose Intolerance, and How Does This Prevalence Differ by Race, Ethnicity, and Age?

The prevalence of lactose intolerance is difficult to discern because studies have varied in their interpretation of what constitutes this condition. To estimate accurately the prevalence of lactose intolerance, one first must define lactose intolerance to permit the identification of those individuals with the condition and the exclusion of those without the condition. By applying this definition to a representative population sample, one can then estimate the prevalence in the general population and assess how this prevalence differs by age and race/ethnicity. We define lactose intolerance as the onset of gastrointestinal symptoms following a blinded, single-dose challenge of ingested lactose by an individual with lactose malabsorption, which are not observed when the person ingests an indistinguishable placebo. Although lactose malabsorption and lactase nonpersistence can be easily identified, they are not equivalent to lactose intolerance.


The prevalence of lactose intolerance in the United States cannot be estimated, despite a systematic evidence review that identified 54 articles, including 15 studies in the United States with a total of 4,817 participants. None of the studies used this definition or evaluated a representative sample of the U.S. population. Seven studies that assessed self-reported lactose intolerance provide limited insight because the self-diagnoses were not confirmed by testing for lactose malabsorption, and the symptoms seen in true lactose intolerance may result from several other conditions such as irritable bowel syndrome. Nine studies evaluated only the genetic predisposition to lower than expected levels of lactase in adults (lactase nonpersistence) without assessing lactose malabsorption or intolerance directly. Five studies reported decreased intestinal tissue lactase activity, and 31 studies addressed lactose malabsorption directly (as evidenced by a positive hydrogen breath test after ingestion of lactose).


Although these studies shed some light on the epidemiology of lactose intolerance (discussed below), they cannot be used to estimate the prevalence of lactose intolerance. Many individuals who have the biologic underpinnings for lactose malabsorption (low lactase levels or a genetic profile associated with low lactase) or who have demonstrated lactose malabsorption do not experience the onset of or an increase in the severity of gastrointestinal symptoms following a blinded lactose challenge. Complicating this further, evidence demonstrates that many who self report lactose intolerance show no evidence of lactose malabsorption. Thus, the cause of their gastrointestinal symptoms is unlikely to be related to lactose.


Despite the limitations in the available studies discussed above, several trends are noteworthy across the studies regarding lactose intolerance, lactose malabsorption, lactase nonpersistence, age, and race/ethnicity. First, lactose intolerance determined by self-report or nonblinded lactose challenge is less frequent across all ethnic groups than is lactose malabsorption determined by breath hydrogen tests or lactase nonpersistence determined by biopsy or genetic testing. Second, lactose intolerance, lactose malabsorption, and lactase nonpersistence vary across racial and ethnic groups with the lowest reported occurrence in European Americans and higher although variable occurrence in African Americans, Hispanic Americans, Asian Americans, and Native Americans. The systematic evidence review notes that the racial and ethnic variability in lactose intolerance following nonblinded lactose challenge was not as extreme as that reported in lactose malabsorption and lactase nonpersistence. Third, lactose intolerance with nonblinded lactose challenge and lactose malabsorption was low in young children, but increased with age. In children younger than 6 years, lactose malabsorption was low in all the studies and peaked between ages 10 and 16 years. Little evidence suggests that lactose intolerance increases in older persons. These trends need to be verified by representative population studies using the case definition of lactose intolerance

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Report from the LI Conference, part 13

Take a deep breath. You're about to be socked with the longest title and longest list of authors of the whole conference.

Evidence-based Practice Center (EPC) Presentation I: Methods of Systematic Review and the Prevalence of Lactose Intolerance and Differences by Race, Ethnicity, and Age
Timothy J. Wilt, M.D., M.P.H.
Codirector, Minnesota Evidence-based Practice Center
Core Investigator, Minneapolis Veterans Affairs Center for Chronic Disease Outcomes Research
Professor of Medicine
University of Minnesota School of Medicine

Want the full list of co-authors? Here. Timothy J. Wilt, M.D., M.P.H.; Aasma Shaukat, M.D., M.P.H.; Tatyana Shamliyan, M.D., M.S.; Brent C. Taylor, Ph.D., M.P.H.; Roderick MacDonald, M.S.; James Tacklind; Indulis Rutks; Sarah Jane Schwarzenberg, M.D.; Robert L. Kane, M.D.; Michael Levitt, M.D.

They didn't all get up on stage at once, or the auditorium would have become unbalanced and slid into the Potomac. In preparation for the conference, a team of experts combed through all the literature, hundreds, maybe thousands, of studies, to collect every one that looked at various populations. They then did a review of all the applicable studies to see what conclusions could be drawn from everything that had been written on the subject.

Some people say that only double-blinded studies (studies in which neither the testers nor the testees known what exactly what is in the test products) are suitable for drawing serious scientific conclusions. All right, me. I've said it.

Here's the problem. There aren't any. None.

Okay, so this isn't a cancer drug that will decide life or death. Maybe we can go with blinded studies, i.e., those in which just the test subject doesn't know whether there's lactose in the drink or not.

None.

What? That can't possibly be? Nobody has ever bothered to blind-test lactose versus a placebo? The Coke/Pepsi challenge was more rigorous than that.

But the disheartening results give the bad news in so many words.

A total of 54 articles met inclusion criteria, including 15 articles from the United States. Studies did not directly assess LI in a blinded lactose challenge but instead assessed unblinded subjective LI symptoms, an inability to fully absorb lactose (LM), or lactase nonpersistence. The data available tended to be from highly selected populations and were likely not representative of the overall U.S. population. We report results according to the following conditions: LI, LM, or lactase nonpersistence. Within these conditions, we further describe findings according to assessment method and populations studied.

Man, that's ugly.

The truth is that scientists got all hot and bothered about LI when they first started looking around the world and finding it everywhere. Most of those studies took place back in the 1970s. Once they found that lactose malabsorption was common and traced the route that lactase persistence took that made most people in northern Europe milk drinkers, they stopped caring. LI isn't really a medical problem, so the medical community has never been terribly interested in studying all the effects. We just don't get sick enough to make us worth their attention.

Is that good news or bad news?

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Saturday, March 20, 2010

Report from the LI Conference, part 12

Back from a short lunch we plunged directly into more presentations.

Aging: Lactose Intolerance and Calcium Absorption in the Elderly
Richard J. Wood, Ph.D.
Associate Professor
Department of Nutrition
School of Public Health & Health Sciences
University of Massachusetts

We're a nation of just over 300,000,000 people. We're also an aging nation. People are living longer than ever before, and the demographic bulge caused by the vastly increased birthrates that represent the baby boomer generation is moving to the older segment of the population. The first boomers are turning 64 this year. By the year 2030 there will be an estimated increase of 33 million people in the 65 and over age bracket, making a total of 25% of Americans. You can't blame the boomers entirely. The oldest will be only 84 that year but a full 5% of the population will be 85 or over then.

What happens to humans as they become older, an older population than ever before? Specifically, what do we know about the elderly and LI? As will be a woefully recurring theme, the answer is "next to nothing."

Although many studies have characterized the prevalence of lactose maldigestion and symptoms of lactose intolerance in various adult populations, there is surprisingly little information concerning this condition in the elderly, especially in the very old (>80 years). What little evidence is available indicates that the prevalence of lactose maldigestion may increase with age in adults, but that symptoms of lactose intolerance do not increase with age.

Little evidence means little evidence. Apparently fewer than a hundred elderly in total have ever been investigated in LI studies.

And those meager results are big time compared to the number of elderly patients tested to see whether lactose malabsorption affects calcium absorption. We just don't know. The possible good news is that tests on younger patients don't show any difference. Keep on having calcium in whatever form you like.

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Thursday, March 18, 2010

Lactose-Free Cheese

The Since Your Asked column in the Medford, OR, MailTribune got a softball question and hit, well, a weak single.

I was recently diagnosed as lactose-intolerant. It's very easy to find lactose-free milk, but is there such a thing as lactose-free cheese or any other food items? If so, are there any local stores that sell them?

The first part of the answer is completely correct, which is I give them credit for a hit.
The good news about a lactose-free diet is that it can still include cheese, but the type of cheese makes all the difference.

"The fresher a cheese, the more lactose will be present," says Gianaclis Caldwell, co-owner and cheesemaker of Pholia Farm near Rogue River. "Hard, aged cheese — it's virtually gone."

The reason is a chemical reaction that occurs in cheesemaking or other types of fermentation. Lactose is a sugar found in all milk. Bacteria, often added as a culture, eats sugar. The longer dairy products are aged, the more sugar is converted into lactic acid. All-natural yogurt is another fermented food that may be digestible for some people with lactose intolerance.

A general rule of thumb is the harder the cheese, the longer it's been aged. Think Parmesan, Swiss and sharp cheddar. To be sure, stick with the highest-quality cheeses, more likely produced with natural methods, rather than additives to alter texture.

The problem with the column as a whole is twofold.

First, as I keep telling people and my NIH LI Conference series should make abundantly clear, you don't need to go onto a lactose-free diet even if you have LI.

Second, the column claims that their shoppers couldn't find any true cheeses marked "lactose-free" in local stores. I can't dispute that, but such cheese definitely exist. My Steve Carper's Lactose Intolerance Clearinghouse website has a page of Reduced Lactose Milk Products that include the names and contact information several brands of true cow's milk lactose-free cheeses.

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Wednesday, March 17, 2010

FAAN College Network

The always-busy, coming-up-with-new-sites, allergy organization FAAN (the Food Allergy & Anaphylaxis Network) has yet another one, the Food College Network.

And that is? The Food Safety News said:

The FAAN College Network is a website that provides college-related food allergy resources for college students and parents. The network provides a searchable database of over 40 colleges and universities with the contact information for food allergy representatives on each campus as well as what steps the schools have taken to accommodate students.

FAAN also provides a list of guidelines for schools to follow in accommodating students with food allergies.

In addition to joining the FAAN College Network, some Colleges and Universities have begun posting more detailed labels near food in the dining halls. Signage in these dining halls can include anything from pointing out common allergens to full ingredient lists. Some schools even offer convenient frozen meals and special items such as gluten-free bread to make things easier for students.

Their FAQ Page is a good place for college-bound students to start.

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Tuesday, March 16, 2010

Pennymint Patties Wins Allergy Free Recipe Contest

Allergiesandme.com, an online store offering selections of allergen free foods, held a recipe contest last month. The Grand Prize winning submission was "Pennymint Patties" by Lori Zook of Pennsylvania.



"My daughter, Jazlyn, is anaphylactic to egg, dairy, peanuts and tree nuts. I have always tried to come up with recipes for the foods she saw and wanted to eat. One day Jazlyn asked my mom what her favorite candy was and she said York Peppermint Patties. Jazlyn adores my mom and wanted to try the candy. Since the store bought version was unsafe, I came up with this amazingly easy recipe that tastes just like the original. I've called them Pennymint Patties because my mom's name is Penny. Since I have developed this recipe, my mom no longer eats the original candy, she just asks me to make another batch of these for her".


You can find links to Pennymint Patties and the other prize-winning recipes on the Allergy and Me recipe contest page.

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Monday, March 15, 2010

Rescue Chocolate's Vegan Egg

With Easter and Passover approaching (don't look at me: the only holidays whose dates I know are the Fourth of July and Cinco de Mayo), a company that brags about vegan Easter eggs and Passover Bark has to get my attention. Mostly because I don't know what Passover Bark is. (If you don't either, the picture is below.)



The news comes from a handy press release telling us the story behind Rescue Chocolate.

The newest do-good gourmet chocolate company, Rescue Chocolate, recently launched two boundary-breaking sweets for the spring holidays.

Candy Easter eggs are a dime a dozen, sometimes literally. The Good Egg from Rescue Chocolate changes that notion. This is a dairy-free "cream"- filled chocolate egg perfect for the Easter basket or Passover table. It breaks bounds in the dairy-free confection world in that it's the country's only vegan chocolate egg actually made with a creamy filling. Those who no longer eat a diet with milk or egg products can now relive that traditional holiday treat from Easters past. This writer was able to try a taste, and the egg did not disappoint. The chocolate cream filling tasted sweet, airy and light; while the chocolate egg shell was dark and smooth as can be.

As with all of the Rescue Chocolate products, this egg has its own mission. The company emphasizes that an unruly pet is not a "bad egg," and instead of giving up said animal, a person needs only to seek out no-cost or low-cost solutions from a vet or animal shelter professional. The egg's presentation, nestled in a cozy wood nest, makes The Good Egg a shoo-in gift for the spring holidays.

As Passover approaches, many observant Jews find themselves dreading the bland food which they annually resign themselves to in the name of tradition. "It's only eight days," they tell themselves, "you can go without the good stuff for eight days." No longer. Rescue Chocolate is offering a limited edition Kosher for Passover-certified chocolate bark. Called Don't Passover Me Bark, it features a matzoh-textured slab of Belgian chocolate with a sprinkling of whole almonds. It's the perfect finish for any Seder meal, and it would make quite a welcome Passover hostess gift.

Both products are cruelty-free, vegan, and certified as Kosher Pareve (with the bark only certified for Passover). And, as with all of their products, consumers feel good shopping because 100% of the net proceeds are donated to non-profit organizations working on animal rescue issues. For the month of March, the United Animal Nations is the beneficiary group for their international animal welfare programs.

Contact information:

Rescue Chocolate
Sarah Gross
917-767-7283
info@rescuechocolate.com
www.rescuechocolate.com

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Sunday, March 14, 2010

Eatright.org

While we're taking a lunch break from the series of LI Conference posts, I'm going to catch up with some of the news about nutrition and products that I've been missing the past couple of weeks.

The American Dietetic Association (ADA) is an important source of good, solid information about dietary issues. They've updated their website, which can be found at www.eatright.org/Public/.

They put out a press release that touted the new features.

1. Diet reviews» This section looks at popular diets (South Beach, the 4-Day Diet, the Flat-Belly Diet, among others) and reviews them from a medical standpoint. A member of the ADA summarizes the diet's claims and strategies, lays out its nutritional pros and cons, and offers a bottom-line critique on whether it's a sound dietetic choice.

2. Question of the day» What is the shelf life of canned vegetables? Is lactose-intolerance the same as a milk allergy? Can pizza be healthy? A new query is posed and answered every one to two days, often with a link to other resources if you're looking for even more information.

3. Find a dietitian» Enter your ZIP code and specialty needs (e.g., celiac disease, weight control), and the site will provide a list of qualified dietitians and their contact information.

4. "Weigh In" blog» Registered dietitians blog about tackling a loved one's eating habits, helping kids navigate snack time, the earthquake in Haiti and other timely topics. The comment section - often the most fun part of blog reading - is sparse at this point, but that might improve as the site attracts more readers.

5. Disease management and prevention» It can be hard to get your general practitioner to discuss diet's role in various diseases, so this section - with information on autism, cancers, kidney disease and others - is a great place to turn for answers.

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Saturday, March 13, 2010

Report from the LI Conference, part 11 [Lunch]

Bethesda, MD, was still recovering from the giant snowstorms of the previous weeks, with sidestreets lined with cars that nobody had bothered digging out from the packed snow thrown up by the plows. That Monday of the conference was chill and rainy and thoroughly miserable (as I found later that day, when I missed a shuttle bus back to my hotel by moments and waited 25 minutes for the next one to arrive, having only a sport coat to break the cold). The good news is that the NI thoughtfully held the conference in a building containing a major cafeteria. The bad news - or at least the comical news - occurred just as the entire conference descended on the cafeteria only to find that the last tray had been scarfed by the NIH's normal inhabitants. The distinguished group balancing plates, soup bowls, bottles, and silverware on top of briefcases, purses, and coats looked more like extras from a Laurel and Hardy movie.

I managed to snag the last seat at a crowded table of the large Lactaid contingent plus Alan Kligerman. We had a mutual admirefest (I have fans, who knew?) and the conversation was lively, if heavy on shoptalk.

Since none of the questions I asked in any of the discussion periods had been answered (nobody has any idea of the duration, rate, or variation of the time it takes to lose lactase production, e.g.) I thought I'd try a more practical question given the expertise I had on hand.

I've been asked multiple times why no lactose-free powdered milk is available to consumers. Alan said that it simply doesn't work. When lactose-free milk is dried, the result is brown, smelly, and bad-tasting.

What likes heat? Chocolate. All the Lactaid people agreed that the chocolate milk Alan had created was one of their best-tasting products, because chocolate loves heat.

So next time you each for a lactose-free carton of milk, try the chocolate. It has approval from on high.

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Friday, March 12, 2010

Report from the LI Conference, part 10

The pattern of lactose tolerance varies widely around the globe. People from northern Europe and their descendents have the highest percentages of tolerance, or ability to drink milk. East Asians have among the lowest. Though I reported yesterday that some African tribes developed lactose tolerance, the majority of tribes did not. These were predominantly the tribes whose populations were enslaved and many of their descendents now live in the United States. Forced matings during the era of slavery ensure that many slave descendents have white, usually northern European, ancestors as well.

This all implies that African-Americans will have an intermediate level of lactose tolerance. That doesn't imply that African-Americans typically consume large quantities of dairy products.

Lactose Intolerance and Ethnic Prevalence
Wilma J. Wooten, M.D., M.P.H.
President
San Diego Chapter
National Medical Association
San Diego County Health Officer
San Diego, California

Wooten's talk spelled out some of the implications of this lack of dairy in African-Americans.


• Less than 75% of African Americans meet the 2005 Dietary Guidelines for Americans, which recommends three servings of dairy foods per day (Beydoun 2008; NHANES data).

• African American children consume only 0.8 to 1.0 servings of milk per day.

• By consuming the recommended three servings of low-fat dairy products (milk, yogurt, or cheese), a number of health benefits can be achieved.

• An estimated 75% of African Americans fail to meet daily calcium requirements because of lactose intolerance.

Much of the problem goes to self-selected attitudes towards dairy. Although only a minority of African-Americans consider themselves lactose intolerant, there is a pattern of excluding dairy.

We'll hear a lot more about dairy later on. But first it's time for lunch.

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Thursday, March 11, 2010

Report from the LI Conference, part 9

With the overview talks done, we finally get to the meat of the conference.

The first section was devoted to the question: What Is the Prevalence of Lactose Intolerance, and How Does This Prevalence Differ by Race, Ethnicity, and Age?

Population Genetics: Evolutionary History of Lactose Tolerance in Africa
Sarah A. Tishkoff, Ph.D.
Associate Professor
Departments of Genetics and Biology
David and Lyn Silfen University
University of Pennsylvania

Holy smoke. That Sarah Tishkoff?

For the fans of population genetics out there, yes, I got to hear from Sarah Tishkoff herself. Why is this a big deal? Let's go back in time, to a post I made in 2006, quoting Scientific American.

According to University of Maryland biologist Sarah Tishkoff, the lead author of a study appearing in today's Nature Genetics, the mutation allowing them to "get milk" arose so quickly and was so advantageous that "it is basically the strongest signal of selection ever observed in any genome, in any study, in any population in the world."

What this means is that despite the nonsensical statements that "humans were never meant to drink cow's milk," lactose tolerance or lactase persistence is such an overwhelmingly positive mutation in humans that multiple populations, totally independent from one another, selected for that version of the gene. Being able to tolerate milk products must have significant advantages. The exact nature of those advantages are still not completely certain. The nutrients that dairy provide are "obvious," to use her word. But even the fact that milk is a drinkable fluid, containing water, may have been of critically importance in areas like Africa, where supplies of potable drinking water were often rare.

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Wednesday, March 10, 2010

Report from the LI Conference, part 8

From the overview talks of Doctors Neu, Krebs, Sibley, Grand, and Chang, the panel pulled together the following summary.

Introduction

Lactose intolerance is the syndrome of diarrhea, abdominal pain, flatulence, and/or bloating occurring after lactose ingestion. These symptoms—produced by malabsorption of lactose, a sugar found in milk and other dairy products—often result in afflicted individuals avoiding dairy products in their diets. Lactose malabsorption occurs because of a decreased ability to digest lactose, due to a deficiency in the levels of the enzyme lactase. Lactase breaks lactose down into two simpler sugars, glucose and galactose, which are readily absorbed into the bloodstream. This enzyme is produced by expression of the lactase-phlorizin hydrolase gene in the cells lining the small intestine.

Infants of every racial and ethnic group worldwide produce lactase and successfully digest lactose provided by human milk or by infant formulas. However, sometime after weaning, in the majority of the world’s children, there is a genetically programmed decrease in lactase (lactase nonpersisters). Lactase nonpersistence variably affects diverse populations in the United States, including Asian Americans, African Americans, Hispanic Americans, Native Americans, Alaska Natives, and Pacific Islanders.

The symptoms of lactose intolerance result from bacterial fermentation of undigested lactose in the colon. Lactose malabsorption can be diagnosed by having individuals ingest a standard dose of lactose after fasting and finding elevated levels of breath hydrogen, which is produced by bacterial fermentation of undigested lactose in the colon. Other diagnostic tools include measuring the lactase activity in an intestinal biopsy sample or genetic testing for the common polymorphism that is linked to lactase nonpersistence. The demonstration of lactose malabsorption does not necessarily indicate that an individual will be symptomatic. Many variables determine whether a person who malabsorbs lactose develops symptoms, including the dose of lactose ingested, the residual intestinal lactase activity, the ingestion of food along with lactose, the ability of the colonic flora to ferment lactose, and individual sensitivity to the products of lactose fermentation.

Current management often relies on reducing lactose exposure by avoiding milk and milk-containing products or by drinking milk in which the lactose has been prehydrolyzed with lactase. Alternatively, lactase nonpersisters may tolerate moderate amounts of dairy products ingested with other foods. However, many individuals mistakenly ascribe symptoms of a variety of intestinal disorders to lactose intolerance without undergoing testing. This misconception becomes intergenerational when parents with self-diagnosed lactose intolerance place their children on lactose-restricted diets (even in the absence of symptoms) in the mistaken belief that they will develop symptoms if given lactose.

The public health burden from deficiencies attributable to lactose intolerance has not been established. However, many adults and children who avoid dairy products—which constitute a readily accessible source of calcium, vitamin D, and other nutrients—are not ingesting adequate amounts of these essential nutrients. For example, most African American adolescents consume inadequate amounts of calcium and vitamin D because they avoid dairy products. Deficient intakes of calcium and vitamin D are risk factors for decreased bone mineral density. This may increase the risk of fracture throughout the life cycle, especially in postmenopausal women. Very low intake of vitamin D can lead to the development of rickets, especially in children of African descent and other highly pigmented individuals. Although reduced-lactose dairy and nondairy alternative products are typically fortified with calcium, vitamin D, and other nutrients, they may be more expensive and less widely available than conventional dairy products. The bioequivalence of these and other calcium supplements is uncertain.

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Tuesday, March 09, 2010

Report from the LI Conference, part 7

The sensitivity of our insides means that diarrhea is a symptom of about a zillion causes. Some of them may be food related, some may be from diseases. If you go a doctor, he or she has to sort through your entire pattern of symptoms to make a proper diagnosis.

Clinical Presentation and Approach: But What if It Is Not Lactose Intolerance?
Lin Chang, M.D.
Codirector
Center for Neurobiology of Stress
Professor of Medicine
David Geffen School of Medicine
University of California, Los Angeles

Dr. Chang had a handy chart to show the common disorders that can be confused with or for lactose intolerance.




That's not six disorders. That's six entire classes of disorders that have to be sorted through.

I don't diagnose people myself, but it's apparent that many of those who write to me don't have lactose intolerance but something else entirely. It's the doctor's job to figure out what, but you can see that's not always the easiest decision to make.

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Sunday, March 07, 2010

Report from the LI Conference, part 6

The next presentation went to the heart of the whole conference. (Why wasn't it first?)

What Is Lactose Intolerance and How To Measure It
Richard J. Grand, M.D.
Professor of Pediatrics
Harvard Medical School
Program Director
Clinical and Translational Study Unit Director
Center for Inflammatory Bowel Disease
Children's Hospital Boston
[You might remember Children's Hospital Boston from my posts pointing to the research they've done to use injections to reduce milk allergy symptoms.]

What causes the different type, amount, intensity, and duration of lactose intolerance symptoms?

•Quantity of ingested milk
•Fat content of the milk
•Rate of stomach emptying
•Rapidity with which the milk is transported through the intestine
•Individual sensitivity to abdominal discomfort
•Capacity of bacteria in the colon to digest lactose not absorbed in the small intestine
•Psychological impact of anticipation of symptoms in those who have had previous symptoms during milk intake.

Quantity of ingested milk is obvious. The next three are related, and interrelated. As I said on Friday, it's critical to remember that most adults who are lactose malabsorbers still have some residual lactase activity. Anything that slows down the transit time of lactose gives the system more time for the lactose to interact with and be digested by that lactase. Whole bunches of factors regulate how fast food empties from the stomach and goes through the intestines, and one factor that is known to slow transit time is the fat content of the milk.

Items five, six, and seven are also related. The quantity of gases and bloating produced by the bacteria fermenting undigested lactose will depend on what types of bacteria you have and also on how sensitive you might be to intestinal rumblings. Knowing - or thinking that you know - that dairy causes problems might increase your discomfort. And there may be physical differences in your sensitivity to pain. We know for sure that people with Irritable Bowel Syndrome, for example, are far more sensitive to pain and pressure in the colon than people who don't have it. That may also be true for people with LI.

Dr. Grand also explained why an ordinary family physician might not want to send you for formal LI testing. The standard, simple Hydrogen Breath Test costs an average of $773. Somebody has to pay that.

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Saturday, March 06, 2010

Milk Promotes Itself to Teens

Most Americans fail to get enough calcium in their diets, teens especially. As Dr. Nancy Krebs reported at the NIH LI Conference, most Americans get the vast majority of their dietary calcium from dairy products.

Put those facts together and you have an opportunity for milk to promote itself to teens. Not surprisingly, the Milk Processor Education Program (MilkPEP), the "Got Milk?" people, jumped heavily onto target market.

Successful Promotions magazine (there's magazine for everything) ran an article on MilkPEP's Get Fit by Finals campaign. The article Got Fitness? by Jean Erickson is available in Flash Paper format, the new worst way to read text on a computer screen. (Yes, it keeps viewers from copying text by highlighting and pasting, but who would want to copy text that they can't read?)

The Internet-heavy campaign features NBA All-Star Chris Paul of the New Orleans Hornets (give them back the Jazz name already) and WNBA All-Star Diana Taurasi. "Activation kits" were also sent to 40,000 schools.



It all seems to work.

Web traffic increased by 17% over previous teen fitness programs, and repeat visits to the site rose to an all-time record.

No hint in the article of how the program handled lactose intolerant, milk allergic, or vegan students, though.

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Friday, March 05, 2010

Report from the LI Conference, part 5

I'm sure some professional jargonistas will come in here and challenge me, but for sheer brain-bending technical mumbo-jumbo in the medical field nothing is more opaquely baffling than the titles of papers on genetics. What would you do with a paper titled "The homeodomain protein Cdx2 regulates lactase gene promoter activity during enterocyte differentiation"?

Whatever that means, it was co-authored by the third presenter of the morning.

Cellular and Molecular Biology of Lactase
Eric Sibley, M.D., Ph.D.
Associate Professor
Division of Pediatrics-Gastroenterology
Stanford University School of Medicine

There are three types of lactose intolerance. If the lactase enzyme never develops at all, then newborns can't have any lactose. They literally starve to death unless a lactose-free formula is given to them almost immediately. This is how LI was first discovered as a medical condition, in fact. Because it exists from birth, this type is called Congenital LI.

Primary LI is the type that most of us have, the natural condition of all mammal. Lactase production declines after weaning, but we can drink milk until that time without symptoms.

A whole medical textbook of conditions - drugs, diseases, surgeries, anything that damages or shocks the intestines - can known out the lactase-making mechanism no matter what your age or status is otherwise. This type is known as Secondary LI.

Why is lactase so vulnerable to being knocked out? Sibley said:

Lactase is a brush border membrane protein produced by enterocytes, the absorptive epithelial cells of the small intestine. The human lactase protein is initially synthesized as a 210–220 kDa immature peptide. The precursor peptide is then processed by glycosylation and cleavage, and finally inserted into the brush border membrane as a mature 160 kDa subunit homodimer.

Lactase is made in the small intestine. Take a biopsy of a section of the inside of the small intestine and a whole invisible world is revealed under a microscope. The insides are covered in tiny projectiles. Imagine a piece of rolled-up shag carpeting and you have the idea. Each projection is called a villus and the outside of the villus, the part that interacts with the broken-down pieces of carbohydrates, proteins, and fats, the part that actually does the digestion, is a membrane called the brush border.

Lactase is made in the brush border, but not in all of it. Lactase is made only at the very tip of the villus. Scientists find that the other enzymes that digest sugars appear the farther you go down the side of the villus, toward the valley (known as the crypt). That's a more protected region than the top. So if anything is going to harm the inside of the intestine, lactase production will go first.

[Why? My guess is that throughout 99% of mammalian history, lactose wasn't very important as a nutrient except for that short time before weaning. Most animals, humans included, live the vast majority of their lifespan after weaning. So if anything has to be first or be most vulnerable, lactase production was the least valuable and bodies could chance that letting it go but protecting the others would lead to higher survival in the long run.]

Here's another fact with huge implications.
Postdecline, the level of lactase activity is 5–10% of childhood levels in most populations worldwide.

That's why most people can have some lactose, some dairy products, even if they are lactose malabsorbers (or lactose non-persisters or are LI in the common use of the term). Your lactase activity doesn't go to zero. It goes down a lot, but not to zero. That helps explain why any activity that helps to slow down the rate at which lactose travels through the intestines (having milk with a meal or having milks with more solids [like whole milk or chocolate milk]) will give your remaining lactose more time to work and reduce overall symptoms.

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Thursday, March 04, 2010

Report from the LI Conference, part 4

Up next was another talk on the basics.

Nutritive Value of Milk and Alternative Sources
Nancy F. Krebs, M.D., M.S.
Professor of Pediatrics and Head of Section of Nutrition
Department of Pediatrics
Health Sciences Center
University of Colorado at Denver

We hear all the time from dairy advocates that dairy needs to be in the food pyramid and be recommended as a major food group because people just won't, at least don't, get their calcium from other sources, even though it's technically possible to.

I knew that, but the the numbers still managed to startle me. "Dairy products provide approximately 70% of calcium in the U.S. food supply." Vegetables are next, at a tiny 8% of the total. Replacing 70% of a critical nutrient is an almost impossible task in less than a generation. Maybe more. That 70% figure has gone down some but it's taken 45 years to do so, and that's with the growth in calcium-fortified foods.

If you do want to avoid milk, the calcium in calcium-fortified orange juice is well absorbed. So is the calcium in calcium-processed tofu and vegetables like kale. The calcium in spinach is not well absorbed, because it contains oxalates that interfere. Fortunately, oxalates are not a common problem in green leafy vegetables, and the ones that do have a high oxalic acid content include chard and beet greens, not huge contributors to the diet.

But if we tried we could just swap out these alternative sources for dairy, right? Sorry, we just don't know. No good studies of whether the functional outcomes of alternative calcium sources are equivalent to dairy have been done.

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Wednesday, March 03, 2010

Report from the LI Conference, part 3

So where do you start a state of the science conference on lactose intolerance. At the beginning. Rimshot. But where's the beginning? Birth? Not early enough. How about with the fetus?

After the usual opening remarks, the conference began with an overview. Appropriately enough, the first presentation started with the basics.

Early Feeding, Human Milk, and the Transition
Josef Neu, M.D.
Professor of Pediatrics
Director of Neonatology Fellowship Training Program
Department of Pediatrics
Division of Neonatology
University of Florida College of Medicine

We're all designed to be introduced to lactose through mother's milk. That introduction happens shortly after birth. And that creates an unexpected dilemma. Since a fetus will never be exposed to lactose, there's no real reason for one to make any lactase. Yet that lactase has to be there and available when the mother's milk comes flowing in.

The body's response is to gradually ramp up lactase availability. Scientists first detect lactase at about 8 weeks of development. Even at 34 weeks, lactase is only at 30% of what will be needed.

That leaves about six weeks for it to reach the needed 100%. (Actually a tiny bit longer. Mothers make what is known as colostrum for the first couple of days of feeding, a special type of milk designed to add to and stimulate the infant's immune system. Colostrum is especially low in lactose.)

What about premature infants? They face a double whammy. Not only are they not fully developed but they are lacking in a critical enzyme to help digest the one food they can eat. No wonder that premature babies faced such long odds in the days before modern science.

Here's where the science gets weird. Despite all this, studies have shown that feeding lactose to premature infants will help them increase lactase levels faster. It's better to give them mother's milk than lactose-free formulas. (After a month or so, the difference disappears as the lactase-making ability increases naturally.)

Even weirder, the partial lactose intolerance that ensues is itself helpful. Some of the lactose reaches the colon, because there's not enough lactase to digest it all. Babies are born with sterile guts: no bacteria. The bacteria enter after birth because bacteria are everywhere and the world is far from sterile. Which bacteria are in the colon make all the difference. The presence of lactose selects for bacteria that are more beneficial. In other words, lactose acts as a prebiotic. "Prebiotics are non-digestible food ingredients that stimulate the growth and/or activity of bacteria in the digestive system which are beneficial to the health of the body."

Think about that. Food companies are spending millions to create prebiotics to add to foods to make them healthier. Humans do it naturally to help premature babies drink their mother's milk. Mind-boggling.

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Monday, March 01, 2010

Report from the LI Conference, part 2

The number of articles on the big NIH LI conference keep multiplying. Google News lists 249, all reading more or all about the same.

• Lactose intolerance misunderstood

• Got milk intolerance? US experts say it's unclear

• Lactose intolerance: Too Little Is Known

• Think You're Lactose Intolerant? Maybe Not

As I reported earlier, these articles are based on a quick telebriefing after the conference along with a draft statement that the panel put out after hearing the presenters and the discussion.

The conclusions in the draft statement are striking.

• Lactose intolerance is a real and important clinical syndrome, but its true prevalence is not known.

• The majority of people with lactose malabsorption do not have clinical lactose intolerance. Many individuals who think they are lactose intolerant are not lactose malabsorbers.

• Many individuals with real or perceived lactose intolerance avoid dairy and ingest inadequate amounts of calcium and vitamin D, which may predispose them to decreased bone accrual, osteoporosis, and other adverse health outcomes. In most cases, individuals do not need to eliminate dairy consumption completely.

• Evidence-based dietary approaches with and without dairy foods and supplementation strategies are needed to ensure appropriate consumption of calcium and other nutrients in lactose-intolerant individuals.

• Educational programs and behavioral approaches for individuals and their healthcare providers should be developed and validated to improve the nutrition and symptoms of individuals with lactose intolerance and dairy avoidance.


Unlike all the other quickie articles, I'm going to talk in depth about the presentations that led to these conclusions. That's going to take a while, because twenty-two separate speakers provided the information that led to these conclusions. The path along the way will be as meandering and repetitious as the plot of Lost but with fewer shirtless hot actors. Bad example, since I gave up on Lost halfway through the first season when it became clear to me that they had no answers and were going to make it up on the fly.

Or maybe good example. I don't want you to bail on me, so I know I'm going to have to share the ending here at the beginning. Let's talk about those conclusions one by one.
• Lactose intolerance is a real and important clinical syndrome, but its true prevalence is not known.

That's starting at the very basics. Obviously LI is real, you might be thinking. Think about this, though. Think about the huge national arguments over whether hyperactivity is real or whether we're dosing kids unnecessarily. Over whether antidepressants should be used for depression or people just need to be told to feel better. Over whether diet or vaccines or the mother's age is a factor in autism. Some problems seem obvious, until you try to find the right box to put them in for definition, for treatment, for cures. Then suddenly they get too slippery to pin down. Everybody feels down some days. That's not the same as depression. Everybody has mood swings, but that's not being bipolar. And everybody has digestive trouble after some foods, but that doesn't mean you have a specific syndrome, condition, disease, or genetic heritage.

What this statement does, as basic as it sounds, is say that LI is real and physicians who see patients complaining about it, i.e. in a clinical setting, should take notice.
• The majority of people with lactose malabsorption do not have clinical lactose intolerance. Many individuals who think they are lactose intolerant are not lactose malabsorbers.

This is important. Not news, but important. We've known this for so long that I talked about in the first chapter of my book Milk Is Not for Every Body. Here's where pinning it down in the box starts. Begin with definitions.

Lactose malabsorption is a genetic condition. At some point in your life, normally in childhood or adolescence but sometimes in late adulthood, your body will reduce the amount of the enzyme lactase that it makes. This condition is also known as lactase non-persistence.

Lactose intolerance is a clinical condition. If you get the symptoms of diarrhea, gas, bloating, and flatulence from dairy products, then you are lactose intolerant.

The two definitions overlap, but they're not at all identical. If you are a lactase malabsorber but never encounter dairy, you'll never have symptoms. Even if you do have dairy products, there's no guarantee you'll have symptoms. You might still have enough lactase left to digest the lactose you've eaten, especially if you're having dairy in a low-lactose form. The bacteria in your colon may be primarily the lactose-digesting varieties that take away most of the symptoms. I've been reporting that dairy is a fast-growing industry in east Asian countries where most of the population are lactose malabsorbers. That's because most people can have some dairy without suffering any symptoms.

I know I have readers who avoid milk for other reasons, but if you're reading this, the chances are high that you're in the group that considers itself lactose intolerant. You have symptoms from dairy products. Lots of symptoms. Bad symptoms. You know it because you've lived through it. Here's the hitch. When formal studies are conducted, some of the people reporting lactose intolerance turn out to be lactase persisters. They make lactase, just as much as the milk drinkers around them. When other people who report symptoms are given a blind taste test - products that may or may nor contain lactose - they often don't have any symptoms at all, even when drinking real milk. What's going on? Nobody really knows.
• Many individuals with real or perceived lactose intolerance avoid dairy and ingest inadequate amounts of calcium and vitamin D, which may predispose them to decreased bone accrual, osteoporosis, and other adverse health outcomes. In most cases, individuals do not need to eliminate dairy consumption completely.

Forget the formal testing. No more than a small percentage of us have ever been formally tested, after all. Most of us get symptoms from milk and then have to decide what to do next. A lot of us stop drinking milk. Some of us avoid all dairy products and even try to cut individual tablets of medications containing lactose out of our diets. You shouldn't. Even though people can get perfectly adequate amounts of all nutrients from a dairy-free diet, the fact remains that the normal American diet doesn't work that way. Without dairy way too many people wind up short of critical nutrients like calcium and vitamin D. Keeping dairy in the diet is easy. Having regular small amounts of dairy works. (I know, because you tell me, that you still keep ice cream and pizza and other good stuff in your supposedly lactose-free diets. That's a good thing, except for the lactose-free product industry.) If you're worried about symptoms, there are lactase pills and probiotics that you can take.

One of the fascinating aspects of the conference is that it seemed to take place in a different world than the "milk is poison" mentality I face out here. The word vegan was never spoken. Dairy was a positive. Not one speaker broke out into nonsense babbling like "humans were never designed to drink the milk of other mammals." Intelligence and science pervaded the air. Visit? Heck, I wanted to live there.
• Evidence-based dietary approaches with and without dairy foods and supplementation strategies are needed to ensure appropriate consumption of calcium and other nutrients in lactose-intolerant individuals.

One thing about the real world. Our digestive tracts rule us. If your digestive system explodes with dairy, then my telling you to have more isn't going to fly. What then? Would taking pills and supplements work just as well as getting the nutrients from dairy products? Again, nobody knows.
• Educational programs and behavioral approaches for individuals and their healthcare providers should be developed and validated to improve the nutrition and symptoms of individuals with lactose intolerance and dairy avoidance.

You tell me, over and over, that doctors don't know anything about LI. And you're right. About half of all doctors will simply tell you to go off dairy if you say you think you're lactose intolerant. They probably won't even send you for testing. An enormous gap exists between the elite researchers in the field and the ordinary primary physicians who see average patients. Lactose intolerance is a punch line. Everybody "knows" what it is, because it makes you fart. And that's funny to almost everybody - except the one farting. We're got to take LI past the fart jokes.

Unless life gets in the way again, I'll start doing that tomorrow.

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Craig Ferguson Loves Lactose Intolerance

Did I just say fart jokes?

We made Craig Ferguson's monolog!

If you watch Craig regularly (he's the host of the Late Late Show, the one following Letterman), you know that he can't resist a fart joke. He'll grab whatever topic he's rambling on about and wrench it totally off its foundations if he can get a fart joke out of it. So of course he's mentioned lactose intolerance about a million times.

Never in a thousand million zillion years did it occur to me that he'd hear about the NIH Conference on LI. I forget about those 249 newspaper articles. He made the conference the centerpiece of his monolog last Wednesday night (or technically Thursday morning). Yes, I'm just catching up with last week's programs. (The conference made a mess of a life that at its best is 10 pounds of entropy in a five pound bag.)

YouTube to the rescue. I've embedded that portion of the monolog here. The lactose-y stuff starts at about 2:10.

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