What is Lactose intolerance?

I have written the original essay on this subject about 15 years ago. I felt that it needed a few addenda. To keep it clear, the new information and comments I have put into italics.

While an ever increasing number of people are diagnosed (or misdiagnosed) with lactose intolerance or lactase deficiency now-days, the myth around this easily controlled problem seems to grow. Interestingly, lactose was noted as a laxative for many decades before lactose sensitivity became recognized as a genuine medical problem.

Recently, I watched in horror, as a usually well informed group of "foodies" on the Internet made a hash of advising a newly diagnosed member on the do's and don'ts of a lactose free diet. It was clear that the malady was poorly understood, resulting in conflicting recommendations.

I have ran a lactose free household for the past 48 years, because my husband, my son and my younger grandson, are severely lactose intolerant. I would like to share what I've learned during those years so that others may lead a less restricted and pain-free life.

Before we begin to talk about the diet, a little biochemistry lesson is in order. Lactose is a natural sugar found in milk. It's two sugars glucose and galactose bound together. Normally in the small intestine, there is enough lactase, an enzyme that splits the bond between the glucose and galactose, to break apart all the lactose molecules ingested from milk. The intestinal walls can absorb glucose and galactose, but not lactose. Think of lactose as too large to fit through the door!

Barred from entry, lactose just sits there, exposed to bacterial action. Bacterial fermentation produces gas causing pressure on the intestinal wall. The intestine tries to get rid of this turmoil with vigorous contractions and flushing with water. Painful crampy diarrhea is the result. These symptoms usually show up, well after the lactose laden meal, during the next 24 hours.

At the beginning I alluded to the concept of mis-diagnosis. Lactose intolerance has become a fashionable problem and many are put on a lactose free diet, the minute they complain of chronic diarrhea. Armed with the understanding of mechanism as I described above, you may be able to ascertain, by careful observation of cause and effect, if lactose intolerance is really your problem or if you need to have your ailment investigated more thoroughly.

While lactose intolerance is usually considered a chronic problem that has to be managed for the rest of a person's life. Temporary lactose intolerance may occur due to infection and/or antibiotic treatment that interferes with the normal functioning of the small intestine.

I wonder if the antibiotics used to treat the animals we eat cause "temporary" lactose intolerance. This is only speculation on my part, but worth considering in light of the fact that lactose intolerance is on the incline.


Understanding Dairy Products.

During the fermentation of milk, such as in the production of most cheeses, yoghurt and buttermilk, the bacteria or yeast in the fermentation culture produces enzymes that break down the lactose. The organisms use lactose as a food, usually producing acidic byproducts from the digestion of the lactose.

This would make most cheeses, yoghurt, buttermilk and sour cream safe. This would be correct if we lived 40-50 years ago, but today many of the dairy products on the shelves are a figment of a chemist's imagination. Often powdered milk is added to the already fermented product to thicken it. Many containers of sour cream reveal on close inspection of the fine print, that it contains cream, cornstarch, and citric acid to imitate the tartness. No bacterial culture at all. The label has to be read very carefully to ensure the product is designated as "cultured" or natural. There is also a school of thought that the term "live culture" on yoghurt labels, as opposed to pasteurized, offers further health benefits. Even if it doesn't, I am all for food that is not processed beyond what is really necessary.

I wrote the above paragraph about 15 years ago. While vigilance is still the key to staying well with lactose intolerance, I have to be fair and report, that there are positive changes afoot and a lot of dairy processors and sausage/salami makers do not add milk where it doesn't belong. Lactose free labeling is on the upswing and I applaud the producers that are considerate enough to practice this.

Sweet creamery butter, the ordinary butter in North America, can also contain a fair amount of lactose, depending on the way it's made, but "European" or "cultured" butter is usually low in lactose because fermented cream is used in the process. Cultured buttermilk, essentially the whey from making cultured butter, is quite safe, however it's still prudent to check the label to make sure that it isn't just milk soured chemically with some acidic ingredient.

In theory, traditionally produced sweet butter and real cream should be low in lactose, since the milk sugar would normally remain in the whey, after separation, however practical experience shows that either the separation is incomplete or milk solids are added to the final product, elevating the lactose content beyond an acceptable level for my family. It is safer, and not much of a hardship to substitute margarine for butter, if cultured butter is not available, and a soy based whipped topping for cream.

Cream cheese products are often high in lactose, although they really shouldn't be. You needn't throw away that favorite cheese cake recipe or give up bagels and cream cheese. Making safe cream cheese is easy. Place a half pint (250 ml) of "cultured" sour cream into a coffee filter and let it drip into a measuring cup for 18-24 hours or until the required firmness is reached. If you give it a stir occasionally you'll get a firmer product faster. You need not refrigerate this while it's filtering. Just cover it lightly with a paper towel to keep out the airborne dirt. The bacterial action at room temperature will further decrease the residual lactose. Save the remaining whey to add flavor and nutrients to cream soups.

Some fresh cheeses, such as ricotta, mescarpone and fresh mozzarella are made by coagulating fresh milk or cream with rennet or an acid. Rennet is an enzyme that causes clumping of the milk proteins. The lactose content in this method remains unchanged therefore these products are not safe for lactose sensitive individuals.

Processed cheeses are generally made by chemical coagulation and are to be avoided. Since most burger-joints use processed cheese, cheese burgers are out, unless they specifically say cheddar is used. Even the cheese-less hamburger or a hot-dog can be a lactose trap, because the bun may have been made with milk.

Most cheeses, with the exception of the ones mentioned above, are low in lactose because they are products of microbial fermentation, followed by some form of aging or curing. Rennet is sometimes listed as an ingredient because at some point in the process the protein needs to be coagulated. The presence of rennet should not be a concern, as long as microbial fermentation has already dealt with the lactose.

If in doubt about a cheese, there is a sure way to tell that a cheese is fermented. Fermented cheese has holes in it, because the microorganism produces gas during the fermentation process. In firm cheeses, like aged cheddar and Parmesan, the pressure of forming the cheese has compressed the hole, but if you look closely a kind of layered flakiness will reveal there were gas spaces before pressure was applied, while the high lactose processed cheese will be velvety smooth. The exceptions to this rule are the soft runny cheeses like Brie and Camembert, which are smooth but low in lactose.

Cottage cheese, theoretically, should be low in lactose since it's traditional preparation is heating fermented milk until the curds clump. However most cottage cheeses sold in North America today are "creamed", meaning that cream, milk or milk solids are added to the cottage cheese. Usually among the plethora of adulterated cottage cheese products, one can find cultured dry cottage cheese (often packaged in a plastic bag) that is quite safe to use as an ingredient in a lactose free diet.


Summary of Safe Milk Products.

The probiotic dairy products and pills, that came on the market recently, are a boon to the lactose intolerant people, because they coat the intestine with good bacteria, preventing the colonization by bad bacteria. Problem areas.

It's obvious that ice cream is the one product that has no easy substitute. In my area a soy-based ice cream substitute was available, but now it can only be bought in specialty stores in bulk. There is a rice based product that is a little more readily available. Frozen yoghurt when it first came on the market, was what the label suggests, frozen yoghurt. However, added milk solids crept into the recipe to the point that it's no longer safe to assume it's low lactose content. Sorbets and sherbets should be milk free, but just to be sure always check the label.

I am happy to report, that improvement has hit this market too and, even in my small town, I can get very palatable lactose free ice cream in a variety of flavors.

Even when you follow a careful diet, occasionally you may fall into one of the many lactose traps. I will give some well known examples of these, but your own vigilance must look for others that are lurking out there, ready to spring on you when least expected.


Lactose Traps:

One of the worst problems is that from time to time the formulation of a safe product changes dramatically without visible notice to the consumer. Reread the ingredients on your trusted milk-free favorites often to make sure the recipe hasn't changed.



Lactose reduced milk, 99% lactose free, is manufactured by adding lactase enzyme to regular milk to split the sugar into its constituents, glucose and galactose. The resulting product is regular milk for all intents and purposes, but the milk sugar is predigested for the lactose intolerant. Since the resulting single sugars are sweeter than lactose, lactose reduced milk tastes a little sweeter than regular milk. The cost of the treatment results in a higher price, but most sufferers will agree that this product is a real boon to their freedom of cooking and baking.

In the early days of keeping a lactose free house, this milk product was not available, but lactase in the form of drops could be ordered by mail. The drops could be added to regular milk, which would then become 99% lactose free in the refrigerator in 24 hours. It was a huge improvement on trying to cook and bake with coffee whitener.

The lactase drops may still be the only option for people living in remote areas where lactose reduced milk is not readily available. Lactase drops can be bought in most pharmacies today.

An excellent frozen dessert can be made by freezing cleaned fruit, then processing it frozen with enough simple syrup to make a slush. Freeze the slush in a covered container. This is a simple and very tasty treat. Another frozen treat is to combine instant pudding made with lactose reduced milk with soy-based whipped topping roughly equal amounts of each. Frozen this combination comes close to imitating ice cream.

Armed with all this information, you should be able to adjust your favorite recipes to eliminate lactose from your household. There is little need to look for new recipes or to drastically alter your lifestyle when eating at home. Lactose intolerance does not have to make life impossible, but careful attention must be paid to labels, ingredients and method of preparation of the foods bought.

The most liberating item to be introduced into the market is the lactase tablet, which can be taken before or shortly after a suspect meal to assist in the digestion of lactose. While cost and inconvenience bar this remedy from routine use, it's a wonderful solution to the problems encountered when eating out or dining at a friend's home. You must however, learn by observation, what parameters and dosage is the best for you.

As you can see reading labels, being vigilant at all times and making informed choices is the only real remedy for this annoying malady. I am optimistic that soon governments will recognize the magnitude of the problem and will require lactose content to appear on the nutrition labels.

Let me assure you though, even if the task seems overwhelming at first, eventually it becomes second nature to look out for problem foods. Then you will enjoy the feeling of wellness that a lactose free diet provides.

If you'd like to investigate this topic further the following sites have good information:

Eva's Hungarian Kitchen
Growing up Behind the Iron Curtain
Eva's Kitchen Confidence
Links to interesting sites
Electronic Books
Other Writing by Eva
Living with Lactose


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