IBS--Free at Last!

New Year's Resolution? Check for Lactose in Prescription Drugs

Are you lactose intolerant? Prescription drugs are an under-recognized source of lactose. Lactose is used as a filler or coating in approximately 20% of prescription drugs and 6% of over-the-counter drugs. Ironically, this is true even for drugs meant to treat gastrointestinal diseases and disorders! Examplesinclue: certain antispasmodics; anti-diarrheal tablets such as Imodium; IBD drugs such as mesalazine, budesonide and prednisolone; pancreatin enzymes. People who take multiple medications  or many capsules and tablets a day might be consuming quite a bit of lactose this way.

While many people may be able to tolerate a gram or two of lactose each day in meds, others may be unable to do so. Do not stop taking prescribed medication if you are concerned about lactose. Ask your pharmacist to help you figure out how much lactose is in your medications, then discuss alternatives with your prescribing physician.

For more information see http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2036.2008.03889.x/pdf

Lactose-Free Milk Really is Lactose Free!

Consumerlab.com recently tested three brands of U.S. fat-free, lactose-free milk: Lactaid, Land O Lakes and Organic Valley. All three brands had no detectable lactose! So, when at home, use these products to keep your protein and calcium intake up.

 

FODMAPs - Dos and Don'ts for Vegetarians

Guest post by: Jillian Smith, Nutrition Student at the University of New Hampshire and Intern 

The FODMAPS elimination diet may seem difficult for vegetarians. Foods commonly consumed by many vegetarians, such as soy products, milk, and legumes are not allowed during the primary phase of the diet. Not only do these foods make up a large portion of the vegetarian diet, but they are also typically high in protein. Vegetarians may wonder how to consume enough protein. However, there are many foods included in the FODMAPS elimination diet that are allowed and provide plenty of protein to the diet. Don't let confusion or worry slow you down. The following list of do's and don'ts will help navigate vegetarians embarking on this diet. 

Do:

• Choose vegetarian high protein, low FODMAPs foods: quinoa, green peas, spinach, nuts, nut butters, seeds, seed butters.
• Make a large batch of seitan and add it to any meal. It works in casseroles, stir fries, or on the grill. It freezes well, too. (Note: seitan contains wheat gluten--in fact it IS wheat gluten.)
• Use lactose-free dairy products instead of other dairy substitutes. Lactose-free milk contains about 8 grams of protein per 8 oz. serving. Lactose-free cottage cheese is another great source of protein containing about 12 grams of protein per half cup serving. 
• Eat breakfast for dinner. Cook up your favorite egg dishes and serve them for dinner. Its a fun way to incorporate this high protein food into your diet. 
• Read labels! Get familiar with food labels of your favorite foods. Find higher protein alternatives. 
• Get creative! Try new and different combinations. Adding new flavorings to dishes will help you forget the absent foods.  

Don't:

• Rely on almond or rice milk for protein. They have only a 1-2 grams of protein per 8 fluid ounce serving.
• Stay on the elimination phase for more than two weeks. You need to liberalize your diet sooner than meat-eaters in order to get adequate nutrients.
• Don't over think it. The FODMAPS elimination diet will be easier with a clear and relaxed mind.

Is Goat Cheese Lactose Free? Label Reading Tips for Cheese.

It is easy to figure out whether a given cheese product contains lactose. Look at the Nutrition Facts for any cheese. First, check the ingredients to make sure there are no added sugars (sugar is rarely added to cheese products). Then, check the "sugars" line.  Any lactose (milk sugar) in the cheese would show up on that line.  If it says "Sugars 0g", then the cheese is essentially lactose free (they are allowed to round down to zero).  For example, the following is label information taken from a log of plain, fresh goat cheese:

Nutrition Facts

• Serving Size 1 oz
• Servings Per Container 4

• Amount Per Serving
• Calories 70 Calories from Fat 50
• % Daily Value*
• Total Fat 6 g 9%
• Saturated Fat 4.5 g 22%
• Trans Fat 0 g
• Cholesterol 20 mg7%
• Sodium 130 mg5%
• Total Carbohydrate 0 g0%
• Dietary Fiber 0 g0%
• Sugars 0 g
• Protein 5 gN/A

So this cheese is allowed on the elimination phase of the FODMAPs diet. Watch out, this trick does not apply to lactose-free milk or, really, anything else except plain cheese.

If you find that lactose-free cheese triggers your symptoms anyway, there could be a few possible explanations:

1. You could be that one person who is so exquisitely sensitive to lactose that you can't tolerate even less than .5 grams of lactose (rounded down to zero), but most lactose intolerant people can handle a few grams of lactose here and there.
2. Note the portion size is 1 ounce. If you eat the whole log of goat cheese, all those "less than .5 grams" could add up to enough lactose to cause a problem!
3. You could have a non-FODMAPs adverse food reaction to milk products, such as an allergy to casein, the protein in milk, or some other type of inflammatory reaction via your immune system.
4. Cheese is high in fat, and there are some people who find that high fat meals trigger symptoms. Try eating smaller portions.

Enjoy your goat cheese in moderation while on the elimination phase of the FODMAPs-elimination diet!

For more information about lactose intolerance, see this post.

 

2011 Book Update: Meats and Milk

There are blessedly few changes to the list of Meats and Milk allowed on the elimination phase of the FODMAPS elimination diet. On page 52 of the book you can add two items:

• lactose free yogurt
• lactose free kefir

Most commercial yogurt is not lactose-free. Modern yogurt manufacture does not allow the yogurt fermentation to continue long enough to break down all the lactose. So far, I know of exactly one commercial lactose-free yogurt (Green Valley Organics, available at Whole Foods) but I'm hoping this will be a 2011 food trend (you heard it here first)! Please share if you know of any other brands of lactose-free yogurt! You can, of course, make your own lactose-free yogurt at home.

Green Valley kefir is also lactose free. Lifeway kefir is widely available and it is 99% lactose free (close enough for most people). Kefir is a cultured, creamy milk drink similar to yogurt but pourable. It's really delightful! Try it, you'll like it!

 

Food: The Forgotten Factor in the Irritable Bowel Syndrome

To those of us with IBS, food is rarely forgotten, but medical professionals sometimes need to be reminded that it is a factor! An excellent review article, just published in Gastroenterology Clinics of North America, will do just that.  If you love science, or if you are one of my dietitian colleagues, it will be well worth your time to read the article. Or, scroll down for my summary!

Food: The Forgotten Factor in the Irritable Bowel Syndrome
Shanti Eswaran, Jan Tack, William D. Chey
Gastroenterology Clinics of North America - March 2011 (Vol. 40, Issue 1, Pages 141-162, DOI: 10.1016/j.gtc.2010.12.012)

Short version:

• Food molecules act as chemical messengers that activate nerves, muscles and hormones, influencing digestion, fluid balance and motility in the gastrointestinal system.
• There are a variety of possible adverse reactions to food. Some are immune mediated (classic food allergy or delayed- or cell-mediated hypersensitivity) and some are not (toxins, physical irritation, lactase insufficiency, fructose malabsorption, FODMAPS in general)
• People with IBS are probably especially sensitive to all of the above.
• There are a number of specific diets for IBS, including fiber supplements (may exacerbate problems), gluten restriction (may be a subset of IBS-D patients who improve with gluten restriction), sugar/carbohydrate restriction (in IBS patients, any form of carbohydrate malabsorption is likely to result in development of symptoms) and finally FODMAPS restriction (growing body of evidence to support efficacy, impressive symptom relief with this more holistic approach)
• IBS--Free at Last! is cited as a reference for details regarding the practical implementation of the FODMAP diet! Very exciting!

The Role of Lactaid Pills

I am often asked whether it is OK to just take a Lactaid pill with milk products during the elimination phase of the diet. No, it isn't.

Lactose is "milk sugar". It is broken down to simpler, absorbable sugars by the enzyme lactase. For various reasons, some people don't produce enough lactase, or maybe the contents of the small intestine are rushing through too fast for lactase to do its job. Though most people who don't produce enough lactase can tolerate a few grams of lactose here and there, other people are exquisitely sensitive and can't tolerate even small amounts. During the elimination phase of the diet, you should not make assumptions about this, even if your impression is that sometime milk products don't bother you. You will learn so much more if you follow the plan and have no lactose during the elimination phase.

Commercial lactose free milk products are treated with the lactase enzyme before they are packaged. Mixing is thorough and complete before the product is packaged, and the product is rendered 100% lactose free. When you take a lactaid pill, the mixing is not as thorough and complete in your body as it is at the dairy plant! The pill may knock the grams of lactose in the product down somewhat, but it will not render it lactose free.

So, during the elimination phase, use only pre-treated, lactose-free milk products, or those that are naturally lactose-free, like hard cheeses. There are lots of brands of lactose-free fluid milk to choose from. Lactaid is the only brand of lactose-free cottage cheese I have seen so far, and Green Valley Organics is the only brand of yogurt I have seen so far.

P.S. After you have completed the elimination diet and challenge phases, there may yet be a role for Lactaid pills. If you discover that you need to limit your lactose consumption, you can use pre-treated products at home, but carry some Lactaid pills with you in case you are unexpectedly "forced" to eat some ice cream or chowder while away from home;) It may help you handle it, even if it doesn't do the whole job.

Green Valley Organics Lactose Free Yogurt

Yes, that's right! Lactose-free yogurt is now available from Green Valley Organics! This is great news for folks on the FODMAPS elimination diet, as well as anyone with lactose intolerance. People do love their yogurt, and with good reason--it is a great source of protein, calcium, phosphorus and other important nutrients! Many of my clients have been disappointed to learn that commercial yogurts are off limits on the FODMAPS elimination diet; although they are touted as having less lactose than the milk they are made from, they do contain enough lactose to cause symptoms in some people. Until now, only homemade yogurt made from lactose-free milk (or cultured for 24 hours from regular milk) was allowed. No more! That market niche has now been filled in a very delicious way--plain, vanilla, blueberry and strawberry flavors are FODMAPS friendly, according to the ingredients listed on the web site products page (always check the label before purchasing any product in case the ingredients have changed)! This brand is available at Whole Foods Markets across the country.

 

Lactose Content of Foods and Beverages

I've posted a new resource for readers and clients on my blog today. Click here or on the link under the Resources section of the far-right sidebar.It is a summary of the lactose content of common foods and beverages.

During the elimination phase of a FODMAPS elimination diet, to keep life “simple” completely avoiding lactose is recommended. However, during the challenge phase and beyond, it may be helpful to know specifically how much lactose is in various foods and drinks. 

For the "lactose challenge" part of the elimination diet, when you are actually trying to provoke symptoms, choose foods HIGH in lactose. You won't get much of a response to your challenge if you only use cheese, for example, since cheese doesn't have much lactose--use milk instead!

If you learn that lactose is a problem area for you, choose foods LOW in lactose in future as you try to manage symptoms. Most, though not all, lactose-intolerant individuals can consume a few grams of lactose at a time without difficulty. If you are very sensitive, please ask your pharmacist to check for the presence of lactose in your medications, as it is often used as a filler or coating. This might not amount to much if you are only taking an occasional tablet, but if you have to take lots of pills it could add up.

Lactose data for some food products was hard to find, so I burned a few brain cells trying to reason out how much lactose would be likely to be in certain foods, such as yogurt. Please see my notes on the handout, and correct me if you have better data than I do (must be from an original source, not just "seen on another web site"). Thanks.

What If I've Tested Negative for Lactose Malabsorption?

If you've tested negative for lactose intolerance, how does that fit into the FODMAPS picture?

First of all, let's review the test for lactose intolerance. The patient consumes a known amount of lactose. If the lactose is poorly digested and absorbed in the small intestine, it continues "down the line" to the large intestine, where it is fermented by the resident bacteria. They produce hydrogen gas as they ferment the lactose. Some of this gas is absorbed into the patients blood stream, where it travels to the lungs and is exhaled. If there is a sharp rise in the amount of hydrogen exhaled after the patient consumes the lactose, that is considered "positive" for lactose malabsorption. One thing to keep in mind is the fact that approximately 20% of us are not colonized by hydrogen-producing bacteria; instead, our resident bacteria many produce other types of gas such as methane or hydrogen sulfide (bad breath, anyone?).  Lactose-malabsorbing individuals in this category will falsely test negative for lactose intolerance on a hydrogen breath test alone, but might be positive if tested for both hydrogen and methane exhalation. The results of the lactose test really need to be viewed together with the patient's history of symptoms after consuming lactose, both during the test and at other times.

If someone has tested negative for lactose malabsorption AND doesn't particularly have a history of symptoms after ingesting milk products, it is pretty safe to say that individual is not lactose-intolerant.

However, even adults who tolerate lactose well in general do have limits to how much lactose they can handle. Because the effects of FODMAPS carbohydrates are additive, excessive lactose intake could put you over the top, and contribute to symptoms mostly caused by the other FODMAPS.

How much lactose is "excessive"? The answer to that question varies from one person to the next, but to put things in perspective, check out these generalizations about the lactose content of milk products:

Fluid milk: 11-14 grams per cup

Lactose-free milk: 0 grams per cup

Evaporated milk: 24 grams per cup

Yogurt: 5 grams per cup

Ice cream: 12 grams per cup

Butter: trace per 1 tsp

Most cheeses: 0-2 grams per ounce

Whey protein concentrate: varies

Whey protein isolate: trace per serving

Click here for more complete info on lactose content of foods and beverages.

To learn more about lactose intolerance and the FODMAPS elimination diet, visit www.ibsfree.net