11: THE BITTER SWEET SUGAR

"A little poison embitters much sweetness."

--UNKNOWN, Old English Homilies. Ser. i, p. 23. (c. 1175)

Lactose is the sugar unique to mammalian milk. Its concentration ranges from less than one percent in seagoing mammals such as seals, sea lions, and walruses to over seven percent in primates such as monkeys, baboons and humans.

Galactose and glucose, the two simple carbohydrates, combine in the breast to make lactose. Galactose is essential for the brain development while glucose provides the needed energy. Human milk contains about 75 grams of lactose per quart while cow's milk contains about 45 grams per quart. In the intestines, lactose breaks down under the influence of an enzyme, lactase. If sufficient lactase enzyme is not present, some lactose escapes into the colon where it proves a good food for the bacteria to thrive on. Bacterial growth, however, brings many undesirable effects. The fermentation of lactose produces carbon dioxide gas and water in the intestine. The results are flatulence, diarrhea and cramps. Infants always have enough lactase enzyme in their intestines. With weaning time approaching lactase levels decrease and nearly disappears when the child is able to take other diets (1 - 1 1/2 years). It is perhaps nature's admonition to assure weaning at the appropriate time, and also a warning to stop using milk. Therefore, those who retain lactase enzyme activity can be aptly called, "milk-freaks." Abnormal are not those who react to lactose but those who do not according to the paradigm of nature. Billions of people around the globe suffer from lactose intolerance. However, it is only since 1965 that we have begun to appreciate it.

Percent of intolerant population:

African Blacks 99
Asian Indians, South Dravidians 97
Nigerians, Yorba & Ibo tribes 99
Filipino 90
Bantus 90
Thais 90
Japanese 85
Taiwanese 85
Indians, American 85
Greek Cypriots 85
Mediterraneans 80
Greenland Eskimos 80
Arabs 78
Ashkenazi Jews 78
Mexicans 75
Turks 72
American Blacks 70
Peruvians 70
Jews 70
Australian aboriginals 70
Maoris, New Zealand 64
Jews, Israeli 58
Samoans, New Zealand 54
Nigerians, Hausa & Fulani tribes 20
Finns 18
Europeans, middle 15
Pakistanis, NW Indians 10
New Zealand Europeans 9
American Caucasians 8
Swiss 7
Northern Europeans 5
Danes 2

The people who best tolerate cow's milk--northern European Caucasians--have been using it continuously for the longest time, suggesting a role of genetic mutation and adaptation. Intolerance to milk by the diverse American population seems to follow the pattern of country of origin. Despite mixing of races, intolerance to milk remains a problem in Americans. About four out of 10 ten Americans are intolerant to milk to some degree.

Further evidence of the evolutionary aspects of milk intolerance comes from the various tribes in Africa. The nomadic Nigerian tribes of Yoruba and Ibo raise no cattle and consume no milk and almost to a man lack the lactase enzyme. To the north the Hausa and Fulani tribes, where milk consumption is traditional, show only 20 percent milk intolerance.

Genetic factors, however, are not the only reason for the wide variations in lactose intolerance. Several nongenetic factors as adaptation, biological (circadian) rhythmicity, hormones, gastrointestinal diseases and nutrition all alter our body's response to lactose. Recent reports from Hawaii confirm the importance of nongenetic factors. Intolerance in homeland Asians and Hapa Haoles (those from Caucasian and Oriental ancestry) is more a function of their eating habits rather than their ancestory. Apparently, we do adapt to lactose intolerance. This does not mean that we start digesting lactose if we keep using it. It simply means as we age we start to tolerate flatulence better and our intestines learn how to control diarrhea better.

Mixing of races brings new foods and breedings. The movement of Caucasians to northern India resulted in reduced intolerance among the natives. The people of southern India, where Caucasians did not mix well, continue to show highintolerance to milk. This was partly a result of racial mixing and partly a mixing of the diets.

People of southeast Asia and those living around Mediterranean Sea, also show high intolerance to milk. Italians show an unusual distribution of lactose intolerance. Those living in the central Italy have the lowest incidence of intolerance while those in the south and north of them have much higher rate of lactose intolerance.

African blacks are highly intolerant to milk but American blacks are less so, although it is still high compared to American whites.Powedered milk is a favored aid staple of the U.S. government to the developing countries. Not appreciating, or perhaps overlooking, the lactase deficiency factor, a recent shipment to an African country brought the wrath of another "imperialist plot" when it produced diarrhea and cramps in the natives. Frustrated, the natives finally made a thicker mixture of milk and used it to whitewash their homes.

The U.S. government programs, albeit well-meaning, are still based on ignorance of the lactase-deficiency problem. Cow's milk, a choice staple of the government-sponsored school lunch programs, is forced upon black children, most of whom are lacotse intolerant. The food stamp program also encourages use of milk and other dairy products, often by people who can least tolerate them. The image of milk as a perfect food is well ingrained in our minds. Many would not conceive that offering milk to a child may not be an act of kindness.

Australians are quickly resolving the problem of heterogeneous milk tolerance among school populations. A recent Australian study shows almost 93 percent of Asians, 56 percent of Greeks and 41 percent of children from other Middle Eastern countries intolerant to milk. Dr. J. C. Brand, author of the study suggests radical changes in school lunch programs. There is a dire need to conduct similar studies in this country also. Unfortunately, the symptoms of milk intolerance are frequently ascribed to psychological or socio-cultural causes. Even when traced, they are often erroneously classified as milk allergies and not as milk intolerance. This confusion arises because the symptoms of intolerance range from disturbances of gastrointestinal tract to mental and emotional maladies. Intolerant subjects not only have diarrhea, but possibly, nasal congestion, asthma, chest infections, skin rashes, cramps, flatulence, lack of mental concentration, failure to thrive and retention of body fluids. Common belief does not associate these symptoms with lactose intolerance. As a result most lactose-intolerant people remain unaware of their handicap. Of the 65 million lactose-intolerant people in this country, only one in 10 have figured out their problem, rest are still wondering.

Contrary to popular belief, symptoms of intolerance do not always appear immediately after exposure to milk. This is another reason why we fail to associate milk consumption with the symptoms.

Worsening lactose intolerance is fat in our diet. This is despite an inverse relationship between lactose concentration and fat in mammalina milks. More people are intolerant to whole-fat milk than to low-fat or skimmed milk. Also, consumption of milk with other fatty foods increases the incidence and intensity of intolerance.

On the other hand lactose containing foods taken with other solid foods produce fewer symptoms of intolerance because of enhanced digestion of lactose.

Lactose intolerance is at times precipitated or enhanced by diseases such as prolonged intestinal infections which reduce efficiency of intestinal cells in producing lactase enzyme. In intestinal bypass surgery, food, including milk, passes through intestines much faster, reducing opportunity to contact with lactase enzyme.

Lactose intolerance is further worsened when alcohol consumption is high. Alcohol increases the sensitivity of the intestine to osmotic loads, or increased water retention in the intestine, reducing threshold of alcoholics to control diarrhea.

Expecting reduced consumption of milk, nature, in a highly astute gesture, makes absorption of calcium more efficient in those who are intolerant to lactose, to conserve calcium. Lactose intolerant subjects absorb about 35 percent of calcium in the food, 10 percent more than lactose tolerant subjects. Still, calcium supplements are recommended, especially for women, to reduce risk of developing osteoporosis when milk is not consumed regularly.The confusion over lactose intolerance symptoms often leads to misconceptions. A popular belief is that phototherapy of jaundiced infants develops lactose intolerance. Recent studies contradict this. Phototherapy does not induce lactase enzyme deficiency and it is not the cause of diarrhea in infants. Lactose intolerance is also not a cause of giardiasis as erroneously suspected.Having said all that's bad about lactose intolerance, here's some good news. Some lactose intolerance may even be good for health. Lactose malabsorbers contract fewer infections of the intestine because the fermentation of lactose produces a volatile fatty acid that inhibits growth of pathogenic bacteria. Children who do not digest lactose well have fewer incidence of diarrhea than those who do. Lactose intolerant adults also have reduced chances of developing senile cataracts. Though not proven conclusively, galactose, a byproduct of lactose, accumulates in the eye lens and produces cataract at older age. Young adults and children, however, use up or break down galactose quickly and it does not represent a threat to the eye lens. Learning to live with milk intolerance begins with identifying it conclusively. The simplest test to determine intolerance is to test if milk-containing foods produce the symptoms. More objectively, a blood sugar test confirms milk intolerance. Lactose, when digested, produces glucose that gives rise to blood sugar. If a 50 gram dose of lactose (equivalent to lactose in one-quart milk) does not produce a noticeable rise in blood sugar, it is a sign of lactose indigestion or milk intolerance.

The stool of lactose-intolerant subjects is acidic and breath full of hydrogen gas. Tests are, therefore, devised to measure these two characteristics, especially the concentration of hydrogen in breath. The test analyzes breath samples for hydrogen every 30 minutes for about three and half hours after taking a 100 gram dose of lactose. Elevated hydrogen concentration in breath signifies intolerance. A simplified procedure recommends taking only two samples, one before and one two hours after the test dose. A concentration rise of 50 ppm (parts per million) or more in the two-hour sample means intolerance to lactose.

These tests are now easily available through your doctor. It is now much easier, than it was five years ago, to find out if your recurring ailments are caused by that white stuff in your refrigerator. Once you find out that your problem is lactose, it should be easy to manage it. Unfortunately that is not the case. No food, especially if made exclusively by nature, is labeled to warn you of lactose. Even processed foods, where such labeling is in order, get around by using confusing language. As a result, most people do not know how to identify foods that contain lactose (appendix 11.1). A common fallacy is to consider milk-free products as lactose-free while a majority of prepared and pre-processed foods contain lactose. Lactose is a popular additive because it is less sweet, cheap and dissolves easily. It, therefore, appears in the most unsuspected products such as margarine or cookies. Consumers need more knowledge about these foods to live comfortably with lactose intolerance.

Fortunately, the U.S. regulations require labeling of all components in a packaged food. Label claims that a product is milk-free may be correct but misleading to a consumer who wishes to avoid exposure to lactose. Milk-free products may still contain whey and milk solids, which may contain lactose or the allergy causing milk proteins.

Fortunately, most food manufacturers are very cooperative and candid about their products. They are willing to supply additional information on product contents. Many will also send recipes, cooking hints and other helpful information that can make your eating more fun. Remember, as the consumer you have the buying power and the manufacturer is there to serve you. Addresses of several manufacturers appear at the end of this chapter (appendix 11.2). Lactose in our diet comes mainly from what we drink. Each of us takes about 180 gallons of liquids per year:

Water 50 gallons
Coffee 35 gallons
Soft Drinks 35 gallons
Milk 25 gallons
Beer 22 gallons
Tea 7 gallons
Juices 8 gallons
Liquor/wines 4 gallons

Milk makes up a significant 13 percent of our total fluid intake which gives us about 10 pounds of lactose to digest. Perhaps there is a need to reduce such strain on our intestines by switching to lactose-free nutritional juices, mineral waters or to imitation milks.

All milk products contain lactose. This includes most instant drinks. Most carbonated beverages are, however, free of lactose and so are most liquors except some cordials. There is no labeling requirement to show lactose in liqueurs. Coffee and teas are lactose-free but some pre-mixed ice teas have lactose added to them.

Imitation milk resembles milk but contains no milk ingredients. Instead, it may contain sodium caseinate, vegetable fat, sweeteners, colors and flavors. Coffee creamers are forms of imitation milk. They contain a large quantity of coconut oil, the oil most damaging to the heart and the arteries. Avoid it.

Many imitation milk formulas contain whey, which contains lactose and the allergy-causing proteins of cow's milk.

Milk substitutes for infants which contain glucose polymers in place of lactose may still cause symptoms of intolerance. For these infants formulas containing only glucose should be used.Lactose-free milks make an excellent substitute for milk in cooking or drinking. Scores of manufacturers of milk substitutes have recipe booklets available, often free of charge (appendix 11.3). Many popular cookbooks also include lactose-free recipes. An alternative to lactose-free milks is to add lactase enzyme to milk or foods. Two types of lactase enzyme substitutes are available, one derived from a yeast, Kluyveromyces lactis, called LactAidR and the other from the fungus, Aspergillus oryzae or niger, called TakamineR.(Other brands of these enzymes are also available.) The second types is more potent. Lactase enzyme is available in the form of tablets or capsules at your local health or supermarket. Or you may contact LactAid people in Pleasantville, New Jersey or Kremers-Urban Company in Milwaukee, Wisconsin for your supply or lactase enzyme. The largest health-food seller, GNC, also sells these supplements.Serendipitously, the technology to curb the problem of lactose intolerance existed before the problem came to recognition. The common process, cheese making, removes lactose. Fermented products such as yogurt, buttermilk, cottage cheese, etc. are low in lactose and also contain bacteria that produce lactase enzyme. In populations where milk intolerance is common, yogurt has long been popular as a substitute.

Fermented foods were first made famous as an elixir of longevity by the Russian writer Metchinkoff in 1908. Every culture and nation has its own brand of cultured milk product: kumiss in Mongolia, kry in Iceland, kefu in Balkan countries, mazum in Armenia, lassi in India and leken in Egypt. The benefits of these products include reduced lactose intolerance, improved absorption of galactose, quick restocking of good intestinal bacteria and removal of some carcinogens from the diet.

Sweet acidophilus milk or cultured milk also makes dietary lactose more tolerable. The bacterial culture added to milk to make it acidophilus provides additional lactase enzyme. Thus other lactose products taken with acidophilus milk are better tolerated.

Cheeses also serve as a good source of nutrition (appendix 11.4). They are high in proteins and fat but contain almost no lactose, removed in the fermentation process. However, not all cheeses have equal nutritional value or health-protecting potential. Cream cheese has more fats, cholesterol and lactose than other cheeses. Nutritional comparisons of cheeses with milk are not fair because it is easier to drink three ounces of milk than to eat an equal portion of cheese.

Yogurt and cheese have also earned a reputation for "binding" stools, or reversing diarrhea. This is due to their reduced lactose content. Therefore, mixing milk with yogurt or cheese is a good idea in keeping you intestines healthy.

Lactose intolerant subjects may not show any symptoms when small doses of lactose are ingested. However, yogurt added to diet allows tolerance to much larger quantitites of lactose coming from other diets. Most of us tolerate about 10 to 15 grams of lactose before the symptoms of intolerance appear. With yogurt, you can tolerate twice as much lactose. This is due to added lactase enzyme coming from the yogurt culture. Even when pasteurized, yogurt retains its ability to improve lactose intolerance.Lactose, the sweetness of milk, proves quite bitter for many. It may just be the reason why would want to give up milk. And if you must patronize cow, why not use yogurt, cheese or other cultured products.

APPENDIX 11.1

LACTOSE IN COMMON FOODS

Breads, cereals, etc.

Lactose-free: Yeast-baked bread such as Italian, Vienna, or French breads and most Jewish bakery products, hard, crisp and crusted, made with water, are milk-free. Crackers and snack chips such as ZestaR or SaltinesR.Lactose containing: Soft crust breads are usually made with milk or lactose. Most biscuits, muffins, sweet rolls, doughnuts, and waffles contain milk. Most hamburger and hot dog buns, bread and roll mixes, including the refrigerated or frozen dough mixe. Most dry cereals such as Special KR, Cocoa KrispiesR, Post Fortified Oat FlakesR, etc. Instant cereals and all cereals cooked in milk.

Desserts and fruits. Lactose-free: Yogurt and tofu products. Natural fruits and their juices. Lactose containing: Commercial and homemade desserts prepared with milk or milk products.

Fats and oils: Lactose-free: Butter, vegetable shortening and vegetable margarine. Lactose containing: Most sauces, chip-dips, salad dressings, sour cream and cheese. Non-dairy creamers and margarine may have lactose or milk products added to them. Read the label.

Starches: Lactose-free: Whole potatoes, freshly baked. Most rice and pasta preparations do not have any lactose. Lactose containing: Commercial creamed or scalloped potatoes, au gratin and instant potatoes. Most macaroni and cheese mixes.

Seasonings: Lactose-free: Most spices.Soups. Lactose-free: Most bullion, broth and stock soups. Lactose containing: Creamed, canned and dehydrated soup mixes.

Candies: Lactose-free: Sugar, honey, jams, jellies, marmalades and hard candies. Lactose containing: All chocolate candies and some chewing gums.

Vegetables: Lactose-free: Most fresh and frozen vegetables.Lactose-containing: Creamed, breaded or cheese preparations.

Miscellaneous foods. Lactose-free: Most meats and cheeses. Dried peas, beans, lentils and peanut butter are also lactose-free. Most flavors, extracts, popcorn, pretzels, snack crackers. Lactose-containing: Breaded or creamed meat or egg dishes. Most frozen foods or "TV" dinners and luncheon meats. Cream sauces, drugs like vitamin C tablets.

APPENDIX 11.2ADDRESSES OF FOOD\CONFECTIONARY MANUFACTURERS

Best Foods, Box 8000, Englewood Cliffs, NJ 07632

Baskin-Robbins Ice Cream, P. O. Box 1200, Glendale, CA 91209

The Beech-Nut Corp., Box 127, Fort Washington, PA 19034

Campbell Soup Co., Campbell Place, Camden, NJ 08101

Carnation Foods, 8015 Van Nuys Blvd., Van Nuys, CA 91412

Del Monte, P. O. Box 3575, San Francisco, CA 94119

Durkee Famous Foods, SCM Corp, Westlake, OH 44145

R. T. French Co., P. O. Box 23450, Rochester, NY 14692

General Foods, 250 North Street, White Plains, NY 10625

General Mills, P. O. Box 1113, Minneapolis, MN 55440

Gerber Products Co., Fremont, MI 49412

Hershey, Hershy, PA 17033

Geo A. Hormel & Co., P. O. Box 800, Austin, MN 55912

Keebler Co., One Hollow Tree Lane, Elmhurst, IL 60126

LaChoy Frozen Food Products Co., Archbold, OH 43502Nabisco Brands, Parsippany, NJ 07054Ore-Ida Foods, Inc. P. O. Box 10, Boise, ID 83707

Oscar Mayer Food Products, P. O. Box 7188, Madison, WI 53707

The Pillsbury Co., P. O. Box 550, Minneapolis, MN 55440

The Quaker Oats Co., Merchandise Mart Pl., Chicago, IL 60654Ralston Purina Co., Checkerboard Square, St. Louis, MO 63164

Kitchens of Sara Lee, 500 Waukegan Rd., Deerfield, IL 60015

Swift & Co., 1919 Swift Drive, Oak Brook, IL 60521

Wm. Wrigley Jr. Co., 410 N. Michigan, Chicago, IL 60611

APPENDIX 11.3

LACTOSE-FREE MILK SUBSTITUTES

key: c:cooking; d:drinking; r:recipes.

APPENDIX 11.4

COMPOSITION OF VARIOUS CHEESES (Gram percent)

Cottage,

Mozzarella

Ricotta

#: for comparison; *: milligram percent; N.D.: not detectable; N.A.: not available. Italics indicate highest value in the category. Source: After, Packard, V. S., Human Milk and Infant Formula, Academic Press, 1982, New York, N.Y. pp. 216, 217. N.D.#: for comparison; *: milligram percent; N.D.: not detectable; N.A.: not available. Italics indicate highest value in the category. Source: After, Packard, V. S., Human Milk and Infant Formula, Academic Press, 1982, New York, N.Y. pp. 216, 217.