Low Lactose Diet

Low Lactose Diet

Who's people needed to be on Low lactose diet

•        To answer this question we must know the metabolism of lactose

Metabolism of lactose

•        After the β1,4-glycosidic linkage between glucose and galactose has been hydrolyzed by lactase, monosaccharides are actively transported through the epithelial cell.

•         Galactose is absorbed more efficiently than glucose.

•        Glucose enters the body glucose pool, but galactose is first metabolized to glucose, mainly in the liver.

•        The regulating enzyme of this pathway is UDP-galactose 4-epimerase. If galactose escapes hepatic metabolism, then it will either be metabolized by the enterocytes or be excreted in the urine.

Metabolism of Undigested lactose

•        Undigested lactose can exert an osmotic effect, drawing water into the small intestine.

•        This may accelerate the passage of intestinal contents into the large intestine (Increased peristalsis), and diarrhea occurs

•        Mucosa became hyperemic and edematous.

•        Colonic bacteria some of which have β-galactosidase activity, will metabolise a proportion of the lactose-producing short-chain fatty acids (SCFA) e.g. formic acids, acetate, lactate, propionate, butyrate.

–      Some of these acids, especially butyric acid, are absorbed by the colonic mucosa, to be used as substrate for the mucosa cells,

–       but if the amount of SCFA exceeds absorption capacity, the residue is excreted in the stools, which will become acidic

–      Formic acid is then cleaved by formic lyase to yield hydrogen gas (H2) ,carbon dioxide (CO2), methane (CH4).

•        The result is copious amounts of gas in the large intestine, leading to abdominal distension, pain, rumbling sound (borborygmi) and flatulence.

•        These gases diffuse into the portal circulation and their concentrations in exhaled air can be used as an indicator of maldigested lactose.

Galactosemia

•        Galactosemia: A harmful build-up of galactose and galactose-1-phosphate in the bloodstream and body tissues due to reduced or missing GALT enzyme witch enables the body to break down galactose into glucose for energy

Untreated galactosemia will result in

–      Infants feeding problems and do not grow as they should.

–      Infants can develop cataracts,

–      liver disease 

–      kidney problems

–      Brain damage

–      Death in some cases

•        Even with treatment, some children may develop

–      learning disabilities

–      Girls may have problems with their ovaries.

•        A deficiency of lactase enzyme causes lactose intolerance

•        A deficiency of galactose-1-phosphate uridyl transferase (GALT) enzyme causes galactosemia

People needed to be on Low lactose diet

•        Lactose intolerance

•        Galactosemia

What is lactose intolerance

•        Lactose intolerance is the inability to digest significant amounts of lactose, the major sugar found in milk.

•        Lactose intolerance is caused by a shortage of the enzyme lactase, which is produced by the cells that line the small intestine.

•        Lactase breaks down milk sugar into two simpler forms of sugar called glucose and galactose, which are then absorbed into the bloodstream.

Symptoms of lactose intolerance?

•        nausea, cramps, bloating, gas, and diarrhea.

•        Symptoms begin about 30 minutes to 2 hours after eating or drinking foods containing lactose.

•        The severity of symptoms depends on many factors, including:

–      The amount of lactose a person can tolerate

–       A person’s age

–      Ethnicity

–      Digestion rate.

 How is lactose intolerance diagnosed?

•        The Lactose Tolerance Test.

•         The Hydrogen Breath Test.

•        Stool Acidity Test.

•        Small bowel biopsy

Types of lactose intolerance

•        Genetics: People may be born with a gene mutation that prevents them from producing lactase. Affected babies usually have diarrhea from birth.  This is a rare condition.

•        Primary lactase deficiency is a condition that develops over time. After about age 2 the body begins to produce less lactase, though most people will not notice symptoms until they are much older.

•        Secondary lactase deficiency occurs when injury to the small intestine or certain digestive diseases reduce the amount of lactase a person produces.

–      These diseases include celiac disease, inflammatory bowel disease, and Crohn’s disease.

Who's at high risk to lactose intolerance

1.   Some ethnic and racial populations are more affected than others.`Prevalence is:

•        7-20% - Caucasians (lowest in north Europe) ,

•        80-95% Native American,

•        65-75% Africans and African Americans,

•        50% Hispanics

•        > 90% Eastern Asia, Jewish descent

2.   Infants born prematurely are more likely to have lactase deficiency because an infant’s lactase levels do not increase until the third trimester of pregnancy.

Where's lactose found

•        Lactose is found in

–      milk

–      In all dairy products

–      Any processed foods which contain milk.

Hidden source of lactose

•        Lactose is often used as a filler in many processed foods such as

•        bread and other baked goods

•        processed breakfast cereals

•        instant potatoes, soups, and breakfast drinks

•        margarine

•        lunch meats (other than kosher)

•        salad dressings

•        candies and other snacks

•        mixes for pancakes, biscuits, and cookies

•        powdered meal-replacement supplements

•        instant coffee

•        Check if any of your medications contain lactose. such as oral contraceptives, and some tablets for stomach acid and gas

•        Learn to read food labels with care, looking not only for milk and lactose, but also for words such as whey, curds, milk by-products, dry milk solids, and non-fat dry milk powder. If any of these words are listed on a label, the product contains lactose. 

Lactose intake

•        Average adult ingests 300 gram of carbohydrates per day

–      52% starch

–      37% sucrose

–      5% lactose (mainly in milk)

–      3% fructose

•        Lactose makes up about 2-8% of milk by weight and 4.8%  of whey.

 

•        Treatment

•        Lactose intolerance is easy to treat.

•        No treatment can improve the body’s ability to produce lactase, but symptoms can be controlled through diet. (dietary changes)

 

you can treat symptoms by four general principles:

1.   Reduced dietary lactose intake

•        Through trial and error, you can determine what amount you can tolerate.

•        you may try consuming small amounts of milk or dairy products with meals because lactose may be better tolerated when eaten with other foods

•        Some people can eat yogurt without problems, especially yogurt with live cultures.

2.   lactase enzyme replacement can be used for people who experience symptoms from small amounts of lactose

3.   Maintenance of calcium intake

 

•        Young children and infants with lactase deficiency should not consume lactose-containing formulas or foods until they are able to tolerate lactose digestion.

•        Most older children and adults do not have to avoid lactose completely, but people differ in the amounts and types of foods they can handle.

–      For example, one person may have symptoms after drinking a small glass of milk, while another can drink one glass but not two. Others may be able to manage ice cream and aged cheeses, such as cheddar and Swiss, but not other dairy products. People can also tolerate more lactose by having smaller amounts of it at one time.

–      Small doses of lactose, of up to 10-12 g, are tolerated without GI symptoms

•        The level of dietary control needed with lactose intolerance depends on how much lactose a person’s body can handle.

• Low lactose diet: < 10 grams lactose per day

• Lactose free diet: all sources of lactose are avoided

•        Lactose-reduced milk and other products are available at most supermarkets. The milk contains all of the nutrients found in regular milk and remains fresh for about the same length of time, or longer if it is super-pasteurized.

•        Calcium

•        Milk and other dairy products are a major source of nutrients.

•        One of the most important of these nutrients is calcium.

•        Calcium is essential for the growth and repair of bones throughout life.

•        In the middle and later years, a shortage of calcium may lead to thin, fragile bones that break easily, a condition called osteoporosis.

•        A concern for both children and adults with lactose intolerance is getting enough calcium in a diet that includes little or no dairy products.

•        Recommended calcium intake by age group

•        Calcium content in common foods and Alternative Sources of Calcium

•        Why should milk, yogurt, and cheese be a part of my diet?

•        Milk, yogurt, and cheese are

    nutrient-rich

–      Calcium (Ca)

–      Protein 

–      Riboflavin B 2

–      Vitamin B 12

–      Phosphorous (P)

–      Potassium (K)

–      Niacin

–      Vitamin A

–      Vitamin D

•        Yogurt

•        Yogurt made with active and live bacterial cultures

•        Yoghurt may be tolerated by some individuals as some of the lactose is predigested by the yoghurt's bacteria.

 

•        When yogurt enters the intestine, the bacterial cultures (Lactobacillus bulgaris or Streptococcus thermophilus). convert lactose to lactic acid, so the yogurt may be well-tolerated due to a lower lactose content than yogurt without live cultures.

•        Frozen yogurt does not contain bacterial cultures, so it may not tolerated.

•        Yogurt is a good source of calcium.

•        Calcium is absorbed in the body only when enough vitamin D is present.

 

•        People with lactose intolerance may not be getting enough vitamin D.

•        Vitamin D comes from food sources such as eggs, liver, vitamin; Regular exposure to sunlight.

•        Complications of lactose intolerance

1.   Osteopenia: a very low bone mineral density. If is not treated, it can develop into osteoporosis

2.   Osteoporosis: bones become thin and weak. If you have osteoporosis, your risk of getting fractures and broken bones is increased.

3.   Malnutrition: occurs when the food that you eat does not give you the nutrients that are essential for a healthy functioning body. If you are malnourished, wounds can take longer to heal and you may start to feel tired or depressed.

4.   Weight loss: excessive weight loss can damage your health,

•        Sample Meal Plan

•        Breakfast

1.   Toast with margarine and spread (e.g. jam or honey)

2.   Breakfast Cereal with Calcium enriched Soy milk

3.   Coffee with Low Lactose milk

•        Morning Tea

1.   Piece of Fruit

•        Lunch

1.   Sandwich with hard block cheese and salad

2.   Glass of Water

•        Afternoon tea

1.   Soy Yoghurt

•        Dinner

1.   Grilled steak with mashed potato (made using low lactose milk) and vegetables

2.   Tinned Peaches with lactose free fruit ice

•        Supper

1.   Fruit toast with margarine

2.   Cup of tea with sugar and low lactose milk

•        Sample Meal Plan

That Sample Diet Provides the Following

Calories 1800

  

Protein 93 gm

CHO 261gm

Fat 48 gm

          Sodium1700 mg

 

Potassium 3533 mg

 

•        References

•        http://ethesis.helsinki.fi/julkaisut/laa/biola/vk/peuhkuri/chap2.html

•        WebMD

–      http://www.webmd.com/digestive-disorders/primer

•        American Academy of Pediatrics

–      http://www.aap.org/

•        American Dietetic Association

–      http://www.eatright.org/

•        Dietary Guidelines for Americans and MyPyramid

–      http://www.health.gov/DietaryGuidelines/

–      http://www.mypyramid.gov/

•        National Dairy Council

–      http://www.nationaldairycouncil.org

•        Office of the Surgeon General

–      http://www.surgeongeneral.gov/

•        http://en.wikipedia.org/wiki/Lactose_intolerance

•        http://www.essortment.com/all/whatislactose_riry.htm

•         Ruth A. Roth, (2003), Nutrition and diet therapy, 8th Edition, Delmar Learning, Canada

•         Joan Rodés‏, (2007), Textbook of hepatology: from basic science to clinical practice,  3rd Edition, Blackwell  Publishing, Hong Kong