IBS--Free at Last!

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.

 

Need to Gain Weight? High-Cal, Low-FODMAPs Foods

Some people with IBS are in the very difficult position of needing to gain weight, yet having to limit food choices and portion sizes to avoid setting off their IBS symptoms. Believe me, people who are underweight get plenty tired of cracks about how lucky they are. It isn't funny; it can be scary to be underweight, and even harder to gain weight for some people than it is for the rest of us to lose it.

High calorie intake may be needed for weight gain, or to support high levels of activity such as training for a marathon or working a demanding physical job. One memorable patient of mine was a tall, slightly underweight 18 year old male college student who had a very physical summer job, played soccer for a couple hours after work most nights, and had a lovely mom who prepared mostly vegetarian food (read: beans) at home, and plenty of it. He had to consume thousands of calories a day to support his calorie needs--how to do it, without blowing up!?

It is helpful to recall that oils do not contain any FODMAPS carbohydrates. Oils contribute 9 calories per gram, versus only 4 calories per gram from protein and carbohydrate. So the #1 weight gain strategy for FODMAPs sensitive individuals or those on the elimination phase of the diet is to EAT MORE HEALTHY FATS, such as olive oil, canola oil, any kind of nut or seed oil, peanut or almond butter. I know, I know, you've always read that people with IBS shouldn't eat too much fat, but is that really true for you? Try it and see for yourself, before you limit your fat intake unnecessarily, based on over-generalized advice. You might be able to tolerate more healthy fat than you think. There is a huge difference between a tablespoon of olive oil (13.5 grams of fat) and a Bloomin' Onion (134 grams of fat--ouch). Just because fried foods make you feel sick, doesn't mean you can't put olive oil on your salad, or drizzle your roasted veggies liberally with oil. If you have to limit fat intake because of another medical condition, you will need the assistance of a registered dietitian to help you plan your weight gain.

Foods high in protein are the next best low-FODMAPs source of calories for weight gain, again because they are automatically low in both sugars and fibers. If you need to gain weight and you don't have any other health issues such as kidney stones or kidney disease that would make it inadviseable to eat more protein, you might try eating bigger portions of foods in the Allowed Meats/Milk section of the elimination diet, for example:

• Beef
• Pork
• Chicken
• Fish
• Seafood
• Lactose-free milk
• Lactose-free yogurt or kefir
• Lactose-free cottage cheese
• Hard Cheeses
• Eggs
• Puddings and custards made with lactose-free milk, eggs, and granulated sugar

You must try these things for yourself to see if you tolerate them. Don't over-restrict based on one-size-fits-all advice that people with IBS shouldn't eat red meat, for example.

There are a few commercial weight gain products that look FODMAPS-friendly based on their ingredients and would be worth trying:

• Boost
• Carnation Instant Breakfast (bottled, not the powdered mix)

Please comment on this post with your weight gain suggestions for other readers. Thanks!

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!

 

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.

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.

Lactose 101

Lactose is known as "milk sugar." It is present in the milk of all mammals, including human, cow, goat, sheep, etc. Most babies and young children all over the world can handle lactose in their diets without a problem. After all, milk is meant to be their primary food! But, as we get older, we may lose the ability to tolerate lactose, especially if we are of Asian, African or Native American descent.

Lactose intolerance can exist on its own, or it can be part of the larger IBS picture. The FODMAPS elimination diet in IBS--Free at Last! can help you figure out how lactose fits into your IBS scenario.

When lactose-intolerant people eat or drink large amounts of lactose-containing foods or drinks, they may get abdominal pain, flatulence, bloating or diarrhea. Small amounts of lactose may be well tolerated, so even lactose-intolerant people may be able to eat cheese or yogurt, or have a little milk in their cereal or coffee.

Milk products are important food sources of protein, calcium and vitamin D, so it's important not to stop consuming milk products without making a plan. One solution might be to drink specially treated, lactose-free milk and milk products. Yogurt is naturally lower in lactose, and most hard cheeses have just a trace. Drinking milk as part of meal helps, too. You might tolerate milk products better on a day that doesn't include a lot of other problem sugars and fibers. All of these variables can make people unsure whether they have a problem with lactose or not!

Diagnostic lactose-tolerance tests are available. But many people figure this one out on their own with a couple of glasses of milk or a big milkshake on an empty stomach! Need I say more?

More technical description of lactose

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Goat's Milk and Goat Cheese

The question often comes up as to whether goat's milk might be tolerated better than cow's milk by lactose sensitive individuals. The short answer is: probably not. Goat's milk does have slightly less lactose than cow's milk, but probably not enough to make a difference for most people. (Note that the proteins in cow's milk and goat's milk are different enough so that some people with an allergy to cow's milk may be able to consume goat's milk, but that is really a separate subject.)

What about that delicious goat cheese that has become so popular? How does that fit into the FODMAPS elimination diet? Like cow's milk cheeses, there is less lactose in cheese because most of it is carried off in the whey, which is separated from the curd during the cheese making process. However, because it is not an aged (or ripened) cheese, goat cheese does have a small amount of lactose in it. It can still be eaten, even on the elimination phase of the diet, if the portion is small. Like other non-aged cheeses, the portion of goat cheese should be limited to 1 oz during the elimination phase of the diet.

Lactose, also know as milk sugar, is the predominant carbohydrate in milk of any species: cow, goat or human. People who don't produce enough of the enzyme, lactase, can't digest lactose. They experience, bloating, gas and diarrhea when they consume it.

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Comparing the FODMAPS Elimination Diet With the Specific Carbohydrate Diet (SCD)

The Specific Carbohydrate Diet (SCD) is a very popular diet developed many years ago by Elaine Gottschall to help people suffering from a variety of GI complaints manage their illnesses by controlling the types of carbohydrates in their diet. Sound familiar?

I will not attempt to explain the SCD; the rest of this post assumes that you are familiar with the basics of the SCD. For more SCD information, click here. I'd like to highlight just a few similarities and differences  between the SCD and the FODMAPS elimination diet.

The main similarity is the underlying principle that malabsorbed carbohydrates are fermented by colonic microbes, and that symptoms result.

The differences, I believe, are due to changes in our understanding of sugar absorption and malabsorption, and to advances in food technology that had not taken place at the time Ms. Gotschall wrote her book.

One significant difference between the two diets regards the now better understood role of fructose intolerance as a cause of GI symptoms. The SCD relies heavily on honey as a sweetener. Honey has a lot of excess fructose, and is not allowed on the FODMAPS elimination diet. Apples, which also contain a lot of fructose, are allowed on the SCD but not on the FODMAPS elimination diet. On the other hand, granulated sugar is allowed on the FODMAPS diet but not on the SCD.

On the SCD, well fermented yogurt and certain cheeses were the only milk products allowed. With the availability of lactose-free milk on the market, the FODMAPS elimination diet does allow consumption of fluid milk, and products made with lactose-free fluid milk.

An important philosophical difference I will point out regards adherence to the diet. Dr. Gottschall was convinced that only absolute adherence to the diet over an extended period of time could restore the individual to health. She did not encourage experimentation or variation from the SCD dietary principles. With the FODMAPS elimination protocol, on the other hand, experimentation and food challenges are encouraged after the initial elimination phase; "problem foods" can be consumed in moderation. The the aim of the FODMAPS elimination diet is limiting IBS symptoms to a tolerable level, selected by the client. Perhaps this is not as ambitious as the cures to which Dr. Gottschall aspired. It seems there is a place for both of these approaches, depending on the needs and medical condition of the individual.

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Cheddar Cheese and Lactose

Aged, natural cheddar cheese is allowed on the FODMAPS Elimination Diet.

Have you noticed lactose-free label claims on some brands of cheddar cheese, including Cabot and Kraft? The labels I have before me state "Contains 0 g of lactose per serving."

Today I had the opportunity to speak with a representative of Cabot Creamery Cooperative at a meeting of the Maine Dietetic Association. She explained that during the cheddar cheese-making process, the curds and whey are separated. Lactose is present in the whey, and is therefore drained off. The cheddar cheese is then aged.  During aging, bacteria ferment and break down any lactose that remains. The resulting cheese is lactose free. (The same is less true of softer, un-aged or less-aged cheeses, which may contain more whey and have undergone less bacterial fermentation.)

When you are looking at the Nutrition Facts for any cheese, 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.  Enjoy!

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