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.

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.

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.

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

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?

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.

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.

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.

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.

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

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Three Strikes And Out For Jenny McCarthy

Jenny McCarthy, the anti-vaccine, give-your-Autistic-kids-any-treatment-no-matter-how-crazy activist is backing off some of her claims.

No, not because she's seen the light and realized that science might have more insight into these issues than she does. The real reason is so horrifying that it's difficult to put down in words. Her son may never have been autistic in the first place.

I emphasize the word "may." But in a long interview with Time magazine, the possibility emerges that she - or her doctors - misdiagnosed Evan. There's no question that at one time his autism was pronounced "conclusive." The article suggests that the passage of time may require a second look at this pronouncement.

Or is this the truth? There are dark murmurings from scientists and doctors asking, Was her son ever really autistic? Evan's symptoms — heavy seizures, followed by marked improvement once the seizures were brought under control — are similar to those of Landau-Kleffner syndrome, a rare childhood neurological disorder that can also result in speech impairment and possible long-term neurological damage. Or, as other pediatricians have suggested, perhaps the miracle I have beheld is the quotidian miracle of childhood development: a delayed 2-year-old catching up by the time he is 7, a commonplace, routine occurrence, nothing more surprising than a short boy growing tall. It is enraging to the mother to hear that nothing was wrong with her boy — she held him during his seizures, saw his eyes roll up after he received his vaccines — and how can you say that she doesn't know what she knows?

The author of the article, Karl Taro Greenfeld, wrote Boy Alone: A Brother's Memoir, an account of his family's struggle with autism. As the above sentence proves, he is completely sympathetic to family concerns and the feelings both of helplessness and the overpowering urge to do something. Yet he is also aware that doing something may lead to more harm than good.

Though close to 80% of American children receive the standard battery of vaccinations, skepticism about their safety remains widespread, in part because of the antiscientific clamor of the McCarthy camp. Enough parents are refusing to vaccinate that some long-dormant maladies, like measles and meningitis, have re-emerged. Nonvaccination rates among kindergartners in some California counties have been reported at 10%. To McCarthy's opponents, from the public-health officials at the Centers for Disease Control and Prevention (CDC) to the pediatricians of the American Academy of Pediatrics, this makes McCarthy much worse than a crank: she's a menace to public health.

Yes, she is. That's the real pity. I'm sure every one of us has had the feeling that our doctors were not paying us close enough attention, not listening clearly to our concerns, not helping nearly enough. Jumping from there to a national campaign against a true cure, a campaign that has lead to the death of children from diseases we thought almost eradicated, cannot be excused. That McCarthy is backing off her rhetoric is too little, too late. She needs to bow out of the public eye entirely.

Science isn't always right, and too often it knows way too little. When it is right, mindless opposition kills people. Literally so. It's too high a price to pay.

Blood Test Might Sort Out Milk Allergies

Since the NIH Lactose Intolerance conference I've been reporting on gave summaries only of previously published research, I interrupt here for some breaking news on a closely-allied front.

The HealthDay News service reported that:

A blood test may help identify children with milk allergy who can tolerate baked-milk products and those who may have a serious allergic reaction to any form of cow's milk, a new study shows.

Previous research found that up to 75 percent of children with milk allergy can tolerate heated milk.

This new study found that immunoglobulin E (IgE) antibodies from children who reacted to both baked milk and unheated milk bound to more epitopes than IgE antibodies from children who had an allergic reaction only to unheated milk. There was a direct link between the severity of the allergic reaction and the number of epitopes recognized by IgE antibodies from a child.

"IgE antibodies can travel to a type of cell that releases chemicals and causes an allergic reaction. Each type of IgE has specific 'radar' for each type of allergen, such as cow's milk. An epitope is a site on a particular molecule, such as a milk protein, that stimulates specific immune responses," according to a news release from the American Academy of Allergy, Asthma & Immunology.

The actual report will be released tomorrow, Saturday, at the Academy's annual meeting.

Report from the LI Conference, part 1

So what is a state of the science conference? I didn't know what to expect.

I've been to - and delivered papers at - large academic conferences. Those are like airports. You get bunches of people coming together in one place for the purpose of going off in random directions. (There is little that's more random than a collection of papers read at the Popular Culture Association conference.) The papers are all on new research, have nothing to do with one another, and are declaimed to small segments of the audience, with no questioning afterward.

At the other end of the spectrum, I've read a lot about scientific gatherings in which the twenty experts in the field of gyrocentric quantum alluvial mastodon theory get together to announce a breakthrough in the timing of Ur-bottle capacitors, devolving into a shouting match between the proponents of cylindrical constructs and the devotees of conical containers.

A state of the science conference fell somewhere in between, although with a z-axis that made it distinct. That third dimension is what is sometimes called meta-analysis. The specialists gathered were not there to present new research - no "dose 20 people with lactose and see what happens" - but to scour the existing academic and medical research, as well as clinical practice, and try to present a picture of what we know and what we do at the current time. The hope is that by taking this comprehensive overlook at today, what is needed to do to improve the medical advice for tomorrow will become more apparent.

To do that, the presenters have a target audience, a panel, made up of knowledgeable experts who nonetheless "have no financial or other conflicts of interest pertaining to the topic under consideration." This isn't easy to do. In a small field like lactose intolerance, it's likely that any expert will be a consultant to various companies, either pharmaceutical firms or product manufacturers, get grant funding from such companies, or at least get paid to speak at various events.

There's nothing inherently wrong with any of this. Although I've never received money from anyone, I've consulted on brochures about lactose intolerance for the American Dietetic Association and the Wegman's supermarket chain. Lending whatever expertise I've gained and spreading proper facts and information is my purpose.

Sometimes consulting looks bad. And sometimes consulting really is bad. When research gets changed, buried, rewritten, reinterpreted, or propagandized because of these ties scandals occur and the faith of the public in science is damaged.

There's no reason to think that anything of that sort took place in this conference, but position papers put out by the government are likely to take that extra step of ensuring that a completely unimpeachable layer of bodies is put in between the presentations and final result. So it's the panel who writes the statement that goes out to the public and the scientific community, not the presenters.

After the presenters and panel, a third group is also invited. Since the conference was free and open to the public, anyone interested in lactose intolerance could show up.

The result was as close to an all-star gala as the field can see. The conference was in the memory of Dr. Norman Kretchmer, the grand old man of lactose intolerance, whose article in Scientific American in 1970 brought lactose intolerance to public attention for the first time. Presenters included Dr. Michael Levitt and others whose research I've cited in my books. The audience featured that ball of energy named Alan Kligerman, the man who founded Lactaid and brought lactase pills and lactose-reduced milk to this country. Though he sold off Lactaid may years ago, he still runs AKPharma, maker of Catsip, the real milk, low-lactose product that is the only kind of milk you should serve your pets, who are all lactose intolerant. At lunchtime, he was pounced upon by what turned out to be a large contingent from Lactaid. I was lucky enough to have lunch with them, and they promised me the latest news about Lactaid's activities. I also ran into Andrew Ritter, the founder of Ritter Pharmaceuticals, and inventor of Lactagen. The room was also filled (OK, not filled: scattered among a sea of empty seats) with dietitians, clinicians, and nurses, a sampling of how many different areas of life lactose intolerance touches.

Here's the full listing of speakers and their paper topics. As you can see, after every few presentations, a discussion period followed during which the panel could ask any questions they pleased and so could the audience if any time remained. Time always did and the audience was a major participant.

Tomorrow I'll get into the papers themselves and give you a look inside the workings of the field.

Huge Gaps in Knowledge in LI

Twelve hours of travel time. Ninety-three minutes actually in the air. My brain is frazzled.

I'm back from the National Institutes of Health state-of-the-science conference on Lactose Intolerance. That was the greatest collection of experts on the subject on one place since Thomas Jefferson dined alone. (That's an old Kennedy joke, for those who aren't history buffs. He once told a dinner of Nobel Prize winners: "I think this is the most extraordinary collection of talent, of human knowledge, that has ever been gathered together at the White House, with the possible exception of when Thomas Jefferson dined alone.")

How big a deal was this conference? It made the papers. Unless a genome is involved, nothing about LI ever makes the papers these days.

Many people who think they cannot digest dairy products might do all right if they eat a small amount at a time, but surprisingly little is known about just how many have true lactose intolerance, a government panel concluded Wednesday. ...

"There are huge gaps in knowledge," said panel chairman Dr. Frederick Suchy of Mount Sinai School of Medicine.

Some studies show that people who think they are lactose intolerant actually can digest the sugar, and the NIH panel worried that people who completely avoid dairy products miss an important source of calcium and vitamin D, nutrients important for bone health and possibly other conditions, too.

The panel's advice:

-Seek a doctor's diagnosis, as symptoms may be due to irritable bowel syndrome or another disorder rather than lactose intolerance.

-If diagnosed, studies suggest some people still can tolerate small amounts of dairy, up to a cup of milk, if taken together with other foods. Also, some products like low-fat cheeses contain less lactose.

-Get enough calcium or vitamin D from other sources, such as fortified orange juice, lactose-removed dairy brands, calcium-rich broccoli, soy products or supplements.

If you look closely, you'll notice that even though that article was in the Washington Post, the local newspaper, the actual source is the Associated Press. And the reporter wasn't at the conference. That information comes from the press briefing this morning.

And that leaves me. As far as I know, I was the only representative of the press to attend the conference. Tomorrow, when my brain starts working again, I'll start an in-depth series of posts about the conference.

Gone to the State of the Science Lactose Intolerance Conference

I'm off today to spend a few days at the National Institutes of Health state-of-the-science conference sponsored by the National Human Genome Research Institute and the NIH Office of Medical Applications of Research.

Don't forget that you can tune into the conference or any part of it through the NIH's videocasting site. Here's what it says for Day 1:

View event: You will be able to view the event at http://videocast.nih.gov when the event is live.

Air date: Monday, February 22, 2010, 8:30:00 AM
Time displayed is Eastern Time, Washington DC Local

Description: Be part of pivotal discussions on lactose intolerance--the inability to digest significant amounts of lactose, a sugar found in milk and other dairy products. After weighing the evidence from a systematic literature review, expert presentations, and audience input, an impartial, independent panel will present a statement of its collective assessment of the evidence to address five predetermined conference questions; these are listed at http://www.consensus.nih.gov.

http://consensus.nih.gov/2010/lactose.htm

Author: Sponsored by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the Office of Medical Applications of Research

I won't be blogging while I'm there. Unlike most other bloggers I can't think and type at the same time. Besides, I expect and hope that my brain will be filled to overflowing. See you in a few days when I recover.

Go Dairy Free 2010 Product Lists

The other great lactose intolerance site is Alisa Fleming's GoDairyFree.org.

She's just updated her Dairy Free product lists for 2010.

For the past three years, our popular Non-Dairy Product Lists have connected free-from dieters with thousands of great food options. To keep things current, we spent the past several months updating each listing, and I am happy to announce that the 2010 versions are finally complete. The following are available in an ebook/pdf format in our Go Dairy Free Ebook Store:

▪ 2010 Complete No Dairy Product List for Multiple Food Concerns (cross-referenced for soy, wheat, gluten, and egg)
▪ 2010 No Dairy Product List for Multiple Food Concerns - Just the Subs
▪ 2010 Complete No Dairy Product List
▪ 2010 No Dairy and No Soy Product List
▪ 2010 No Dairy and No Gluten Product List

We lamented over the loss of some wonderful food manufacturers, but are happy to report that many new foods and companies have taken their place. In fact, the complete product list has grown by 50 pages since last year! ...

Keep in mind, the product lists are not limited to specialty brands either. The complete product list contains approximately 5000 food listings, with categories ranging from cheese and cream alternatives to granola, bread, and frozen entrees.

However, for those of you who just want to know the alternatives for traditional milk-based foods (milk, cheese, ice cream, cream, toppings, chocolate, pudding, etc.), we have added a new condensed version of our complete product list called “Just the Subs.” Still 43 pages in length, this "petite" listing is sure to offer several new-to-you dairy alternatives. It is also cross-referenced to note if the products contained soy, wheat, gluten, or egg ingredients at our time of review.

For more information and to obtain a copy, see our Go Dairy Free Ebook Store.

As the name should imply, these are products that are worth real money. So they are not downloadable free. You have to pay for them. Please do so.

More Camel Milk Lactose Nonsense

Camel milk is pretty much like all the other milks that humans drink on a regular basis. According to a respected expert - me, on my Lactose Zoo page - cow's milk has a range of 3.7-5.1% lactose. Sheep's milk is 4.6-5.4% lactose. Goat milk is 4.1-4.7% lactose. And camel milk has a range of 3.3 to 5.0%. There may be some variation at the extremes, but put them onto a chart and they would overlap heavily.

So why do some people, even purported experts, try to claim that those of us with lactose intolerance can drink camel milk with no symptoms? I don't know. And their explanations don't help at all.

"Camel milk also contains lactose but of the non-allergic variety, so any lactose-intolerant person who can’t drink cow’s milk, can drink camel milk," explained Ruquiya Alusmani – the consultant chief of the Nutrition and Dietetics department and a Diabetic Educator at Baksh Hospital in Jeddah - in an interview with Saudi Gazette.

If you think that nobody could possibly talk about lactose of the non-allergic variety and that some blogger is misquoting the Saudi Gazette, I regret to inform you that the quote is actually from the Saudi Gazette.
Needless to say. Sorry, as is obviously needful to say, no lactose of any kind, from any animal, is allergic in any way. Proteins cause allergies. Lactose is a sugar. And lactose from camel milk will create about as many symptoms as lactose from all those other animals' milks.

Massachusetts to Require Food Allergy Warnings

People with food allergies don't want to feel different, don't want to be restricted in where they go or what they do. Yet common sense tells us that restaurants are potential sinkholes of allergens lurking not just in every food but in the utensils used to make the food, even the very air wafting around the kitchen.

What to do? Keep those with allergies out of restaurants? Nobody wants that. What about listing the complete ingredients of every food on a menu? Not practical unless you plan on replacing short, cheap printed menus with electronic books to cover the hundreds of pages of fine print necessary and be updatable every time an ingredient changed.

Massachusetts is planning on a middle course. A story by Stephen Smith in the Boston Globe revealed that the Massachusetts state Department of Public Health will vote in April on whether it should require restaurants and their workers to be better informed about allergies and respond when customers mention their allergies.

Although most peoples' immediate reaction might be, "of course they should," statewide regulations are notoriously bad for getting "shoulds" correct.

What will Massachusetts require?

Every menu in the state would be emblazoned with this admonition: "Before placing your order, please inform your server if a person in your party has a food allergy."

Oh. You'd never have thought of that on your own, I'm sure.

This one sounds a bit better.

thousands of restaurant workers would undergo training and then return to their kitchens, sharing lessons on how to prevent dishes from being contaminated with allergy-inducing ingredients.

Wow. Thousands of trained workers. Can't complain about that. Until you find out that Massachusetts has 17,000 restaurants that the regulations will cover. (None of them fast food restaurants, BTW. They would be exempt for the time being.) Those thousands amount to one per restaurant.

By next January, at least one worker from each restaurant would be expected to undergo training, which largely involves viewing a video Tsai helped create. It would be up to local boards of health, which are responsible for assuring that restaurants abide by food safety laws, to monitor whether establishments are complying.

It's not clear from the article what happens if that one trained employee leaves.

As for the rest of the staff, the regulations "would force restaurants to plaster a food allergy poster on the kitchen wall."

Wow, again.

A slightly more reassuring part of the article is this section:

Suzanne Condon, director of environmental health at the Department of Public Health, described how restaurant staff should respond when a customer reports an allergy to peanuts, for example. "The server is supposed to notify the staff involved with the preparation of the food that a member of the party has a food allergy," Condon said.

That not only means making sure there are no peanuts in the dish the diner has ordered. It also means being vigilant that the utensils and surfaces used in the preparation of that order have not been exposed to peanuts.

That's better, certainly, at least from our point of view as consumers. How feasible this is in a busy restaurant is harder to answer. In a world in which peanuts are forbidden from entire airplanes and school cafeterias because of the danger of accidental contamination, how can a restaurant that uses peanuts in dishes keep them totally separate from all foods?

The regulations introduced yesterday reflect the handiwork of the Massachusetts Restaurant Association and the Food Allergy & Anaphylaxis Network. The Legislature and Governor Deval Patrick broadly endorsed the concept last year by adopting the Food Allergy Awareness Act, leaving the specifics to the Department of Public Health.

Dr. Michael Pistiner of Leominster, who treats patients every day with food allergies, helped develop the regulations. Still, he said yesterday, diners who know they have reactions to certain ingredients must be their own best advocates.

"This is really a ground-breaking law," said Pistiner, an allergist affiliated with Children’s Hospital Boston. "But people with food allergies are still going to need to be vigilant and choose wisely."

Of course, and I would have ended this post with a similar homily. The nicest thing I can say about Massachusetts's plan is that it is a first step that might spark more awareness. It's not a solution in any sense. We have a very long way to go before allergens in restaurant food are properly addressed.

Pamela's Products

Lisa - the Gluten Free Foodie celebrated her first gluten-free cake.

I am so excited that my first Gluten Free King Cake turned out - Ca c'est bon! (That's good!)

I decided to make it easy so I tweaked a few recipes and used Pamela's Products bread mix. This is a combination sweet bread and Challah bread ... YUM! It is not only Gluten Free but Dairy Free and Soy Free too! I used Earth Balance non-dairy non-soy, natural buttery spread and Nielsen Massey Bourbon Vanilla paste to enhance the yeasty flavor of the bread. I purchased the beautiful traditional colored sugars from Williams-Sonoma in Purple (justice), Green (faith) and Gold (power) that represent the three wise men. It is also a tradition to hide a prize - a bean, coin or plastic baby inside the cake to represent the Christ child. The finder of the prize or baby is said to host the following year's festivities. I must get it every year because I love hosting Mardi Gras!

Pamela's Products sounded interesting, so I scouted them up.



They make a variety of gluten-free and wheat-free cookies, biscotti, and baking mixes. Their allergy page says:

Pamela's gluten-free cookies and mixes are produced on 100% dedicated gluten-free machinery.

Pamela's Products have been formulated and produced to be wheat-free and gluten-free. Our products are produced in a facility which also makes products containing: peanuts, tree nuts, dairy, eggs and soy. Should you have any questions or concerns regarding any product in the Pamela's line, please contact us at: Phone 707-462-6605 or email info@pamelasproducts.com.

You can also check that page to see which products are also dairy-free. Most are. A few contain butter, so they probably won't be a problem for those with mild lactose intolerance. The Baking & Pancake mix contains buttermilk, which may therefore have a bit more lactose.

Good General Article on Lactose Intolerance

Shirley S. Wang wrote a nice piece in the Wall Street Journal on lactose intolerance.

Most people continue to produce some lactase, but at much-diminished levels. After they reach their individual threshold and can no longer break down lactose, it passes intact through the intestine until it reaches the colon, where it is finally fermented by the bacteria that reside there. As the bacteria do their job, they produce gas as a byproduct, which causes discomfort and pain as well as symptoms such as cramping and diarrhea.

Training the Bacteria
Some people, after diagnosing themselves, cut out regular consumption of dairy—which can potentially make symptoms worse when they do consume it. The bacteria in the gut can become less efficient at processing lactose if they aren't continually asked to do it. Conversely, people can train the bacteria to tolerate more dairy if they consume it regularly.

She goes on to talk about some of the genetic research into lactose intolerance. In fact, it's clear that she did the interview with Eric Sibley, an assistant professor of pediatrics at the Stanford University School of Medicine, and then wrote an article to justify it.

It's telling that even a well-written, informed article such as this can have so much wrong with it.

Amazingly, Wang never mentions that lactase pills have been available for decades and they are far more effective for far more people than trying to retrain the gut bacteria.

And then there's this:

Dairy products that have gone through some processing, such as cheese and ice cream, tend to have less lactose because the fermentation process breaks some of it down. But those with an intolerance should keep an eye out for lactose that has been added to products like cookies by reading the food label, says Gilman Grave, acting director of the National Institute of Child Health and Human Development's Center for Research for Mothers and Children.

Keeping an eye on ingredients lists is certainly important. But what's that about ice cream being fermented or having less lactose? That's completely wrong. She might have been thinking about frozen yogurt, but that's an extremely odd mistake to make.

We have a long way to go.

iPhone, uPhone, We All Phone for iPhone

With more than 100,000 apps for Apple's iPhone, no one on earth knows what all of them are. Not even Steve Jobs. And what else does he have to do with his time?

Some other people with more time on their hands can explore the Appy Worlds. Like the Coupon Sherpa. I assume it's the Coupon Sherpa. These days somebody might actually be named Coupon Sherpa. Coup, as we like to say, works for the Hartford Courant. This week, Coup looked for apps that could:

help you build a shopping list, find a recipe that suits your dietary needs, cooking capabilities and contents of your kitchen.

The following nine mostly free apps hopefully will help make the process of shopping and cooking easier and more fun.

Number one on the list is of interest to us.

1. Allrecipes.com Dinner Spinner (Free)

Select your ingredients, your meal preference and how much time you want to spend cooking and AllRecipes provides the details. Filters allow you to select dishes for vegetarians, the lactose intolerant, gluten-free diets and more. Includes recipe reviews and ratings.

A Very Naughty But Dairy-Free Valentine's Day

We're all adults here, right? (If not, send the kiddies off to watch the Olympics Opening Ceremony. Right now.)

Valentine's Day may be a day for romance, but most adults want to spell romance S-E-X. Trust a college publication to have S-E-X on its mind. North by Northwestern is Northwestern University’s best independent online publication. I didn't say that. They did.

Myrtle Williams did a funny little piece on Carnal Knowledge that would better have been titled Caramel Knowledge. It's all about edible sex toys and enhancements from candy panties, gummy undies, nipple tassels, to even non-dairy body whipped cream. (Actually, almost all the products are dairy-free, consisting of variations on sugar and more sugar.)

Although the column is about adult topics, there's nothing visual to cause serious trauma unless you have to worry about a thong on a manikin. The Love Potions page on which the body whipped cream can be found on is equally visually friendly but definitely NSFW.