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KEY POINTS:

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  • In general, there are two types of lactose intolerance:
    • Primary lactose intolerance or deficiency (also called congenital deficiency, racial or ethnic lactose malabsorption): 
      The condition in which someone does not produce enough lactase enzyme after weaning
    • Secondary lactose intolerance: 
      The condition which can result from some kind of damage to the small intestine, such as in celiac disease. Tolerance to lactose should return once the intestinal lining is healed; this can take months.
  • In patients with newly diagnosed celiac disease, secondary lactose intolerance is very common because the enzymes (lactase) that digest milk sugar (lactose) are located along the lining of the small intestine where the damage in celiac disease occurs.1 There is inadequate lactase secretion which results in undigested lactose and this draws fluid into the digestive tract causing loose stool or diarrhea. Bacteria which normally live in the colon use the undigested lactose as food and produce hydrogen gas as a by-product, causing bloating and gas 

    Small intestinal bacterial overgrowth (SIBO), a condition that is associated with celiac disease, can also lead to secondary lactose intolerance.
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  • Fortunately, since the damage in celiac disease is caused by gluten, a gluten-free diet heals the intestines, and some people will eventually be able to tolerate lactose again.
  • No two people with lactose intolerance are the same. 
    If you have significant lactose intolerance, you can start by using lactose-free milk or gluten-free soy, hemp, nut, or rice milk fortified with calcium and vitamin D*. Limit the intake of cheese to hard, aged cheeses that are naturally low in lactose. 

    *Note that gluten-free seed, nut and rice "milks" may not be nutritionally complete, including low protein content. 

    Here are a few brands of lactose-free products*:

    • Lactaid®: lactose free and gluten-free milk, yogurt, half and half, eggnog, and cottage cheese. Most Lactaid® ice cream is also gluten-free but, as one example, their "Cookies and Cream" contains wheat and must be avoided. Check each ice cream flavor for gluten.
    • Breyers®: lactose-free vanilla ice cream does not have any gluten listed in the ingredients and can be considered safe on the gluten-free diet.
    • Green Valley®: lactose-free yogurt, kefir, and sour cream are gluten-free. Green Valley tests for gluten content.

    *These manufacturers claimed their products were gluten-free as of 9/20/2011. Read labels carefully as ingredients can change at any time without warning.


    As the gut heals over the next few months, other types of cheeses, ice cream and other lactose-containing foods can be trialed to test your tolerance level 1(see table with lactose content of foods). You may also be able to tolerate small amounts of milk that have been added to food, such as in mashed potatoes or scrambled eggs. For some, the tolerance to lactose is likely to normalize eventually, allowing all gluten-free dairy products to be eaten. 

    Oral lactase tablets may help in the digestion of lactose containing foods and beverages. There are many brands of such tablets including (but not limited to): Lactaid®, Digestive Advantage® Lactose Defense Formula, Renew Life Lactose Stop®, and Dairy Care®. Some of these tablets must be taken immediately before consuming a food/beverage that contains lactose and others only need to be taken every 12 hours. Read the instructions carefully and speak to your doctor or dietitian to find out if you are likely to benefit from lactase tablets
  • Studies have shown that limiting ingestion to 4-7 grams of lactose per day should help prevent symptoms from occurring. 
    LACTOSE CONTENT OF COMMON FOODS AND BEVERAGES3

    Product

    Serving Size

    Approximate Lactose Content (grams)

    Butter

    1 tsp

    0a

    Cheese

    • Cheddar cheese, Swiss
    • Mozzarella
    • Bleu Cheese
    • American cheese

    1 ounce
    1 ounce
    1 ounce
    1 ounce
    1 slice

    0-2
    <0.1
    <0.1a
    <0.2a
    1

    Cottage cheese, 2% milkfat

    ½ cup

    3

    Cream (light)

    ½ cup

    <0.2a

    Cream cheese

    1 ounce

    1

    Evaporated Milk

    1 cup

    25a

    Half-and-Half

    ½ cup

    0.2a

    Ice cream

    ½ cup

    Varies by brand and recipe

    Margarine

    1 tsp

    0a

    Milk (nonfat, 1%, 2%, whole)

    1 cup

    12-13

    Milk, Lactose-Free

    1 cup

    0b

    Nonfat Dry Milk Powder
    (unreconstituted)

    1 cup

    62a

    Sherbet, orange

    ½ cup

    2b

    Sour Cream

    2 tbsp

    0.7

    Sorbet

    ½ cup

    Sorbet does not contain milk

    Whipped Cream topping, pressurized

    2 tbsp

    <0.5a

    Yogurt, low fat

    6 oz

    5 – 10gc
    (note: although yogurt contains lactose, cultured yogurt is generally well tolerated by persons with lactose intolerance)

Reprinted with permission of University of Virginia Health System GI Nutrition Page 
www.ginutrition.virginia.edu), Dec 2012. 

References: Unless otherwise noted, levels are per the USDA National Nutrient Database (SR-25): 
available at: http://www.ars.usda.gov/main/site_main.htm?modecode=12-35-45-00 .

Specific lactose content not available in USDA National Nutrient database; amount listed is total sugar 
content per USDA National Nutrient database referenced above

b Per Lactaid® website: www.lactaid.com 

Per direct communication with several major yogurt manufacturers

 

  • Concentrate on a low-lactose diet rather than a dairy-free diet, unless necessary (ie, a milk allergy).
  • Trialing a low-lactose diet for a short time with improved symptoms can indicate lactose intolerance. If there is uncertainty regarding the diagnosis, your doctor may order a Lactose-Hydrogen Breath Test. This test will need to be booked in advance in a special lab. 

    The Lactose-Hydrogen Breath Test: a person drinks a lactose solution and then breathes into a balloon. At regular intervals, an apparatus called a gas chromatograph measures the amount of hydrogen expelled. 2 Normally, very little hydrogen is detectable in the breath. If the body does not digest lactose, the undigested lactose reaches the colon where the colonic bacteria break it down causing hydrogen and other gases to be released. The excess hydrogen is absorbed by the intestine and eventually exhaled, producing high levels of hydrogen. 4
  • If you have lactose intolerance and are limiting or avoiding milk products, your body could be lacking certain nutrients (such as calcium and vitamin D). 5canned_salmon

    Milk and milk products provide just 10 percent of the calories in the American diet, but deliver:
    • 58% of the vitamin D
    • 51% of the calcium
    • 28% of the vitamin A and phosphorus
    • 26% of the vitamin B12 5
    • a good source of lean protein (nonfat and low-fat choices)
    • Lactose reduced and lactose-free dairy products contain the same amount of calcium as lactose containing dairy products. Lactose intolerance does not affect calcium absorption from food and beverages.
  • Black_Eyed_PeasHowever, if for any clinical reason (such as a dairy allergy or intolerance) or personal reason (you do not wish to consume animal products), there are a variety of non-dairy (lactose-free) calcium-rich foods or calcium-fortified foods available on the market to help you meet your calcium needs. 
  • The word "calcium" will be included in the ingredients list if a food has been fortified with calcium. 

    Since vitamin D is also essential for bone health, try to find calcium-rich foods that are also fortified with vitamin D. 
    Click here for a list of vitamin D rich foods. Scroll to the third page
    GLUTEN-FREE SOURCES OF CALCIUM
    TYPE OF FOOD SERVING SIZE CALCIUM(mg)

    NON-DAIRY FOODS (calcium fortified)



    GF Almond Milk 1 cup 450 (varies)
    GF Rice Milk or Hazelnut Milk 1 cup 300

    GF Soy Milk

    1 cup

    300

    GF Soy yogurt

    2/3 cup

    500

    GF Soy cheese

    1 oz

    200

    FRUITS, VEGETABLES, AND LEGUMES



    Spinach, frozen, boiled

    1 cup

    291

    Orange juice (calcium-fortified)

    1 cup

    266

    Soybeans, boiled

    1 cup

    262

    Turnip greens

    1 cup

    250

    Blackeyed peas, boiled

    1 cup

    211

    White beans

    1 cup

    161

    Bok choy

    1 cup

    160

    Kale, frozen, boiled

    1 cup

    160

    Mustard greens, frozen, boiled

    1 cup

    152

    Navy beans

    1 cup

    126

    Soy nuts, roasted, salted

    1/2 cup

    119

    Pinto beans, canned

    1 cup

    103

    Iceberg lettuce

    1 head

    97

    Green peas

    1 cup

    94

    Oranges

    1 cup

    72

    Broccoli, boiled

    1 cup

    72

    Orange

    1 medium

    52

    Carrots

    1 cup

    48

    FLOURS, GRAINS, AND NUTS (RAW)



    Flax Seed

    1 cup

    428

    Flax seed meal

    1 cup

    332

    Amaranth seed

    1 cup

    298

    Soy flour, defatted

    1 cup

    241

    Teff flour

    1 cup

    239

    Amaranth flour

    1 cup

    207

    Mesquite flour

    1 cup

    198

    Soy flour, full fat

    1 cup

    173

    Teff grain

    1/2 cup

    166

    Corn flour-Yellow
    (Masa, enriched)

    1 cup

    161

    Hazelnut flour

    1 cup

    128

    Garbanzo bean flour

    1 cup

    126

    Buckwheat bran

    1 cup

    104

    Garfava flour

    1 cup

    104

    Potato flour

    1 cup

    104

    Almonds

    1 oz (24 nuts)

    70

    Brazil nuts (dried, unblanched)

    1/4 cup

    56

    White rice, long grain, parboiled, enriched

    1/2 cup

    52

    Quinoa grain

    1/2 cup

    51

    Hazelnuts

    1/4 cup

    39

    PROTEIN FOODS



    Salmon (pink), canned with bones

    3 oz

    181

    Sardines, canned in oil with bones

    2 sardines

    92

    Shrimp, canned

    3 oz

    50

    Tofu, firm (calcium-fortified)

    4 oz

    258

    Tempeh

    1/2 cup

    77

    Reference: Diana L. Saryan, MPH Nutrition Services, BIDMC, 617-667-2565


    HOW TO CALCULATE THE AMOUNT OF CALCIUM PER SERVING ON A FOOD LABEL FROM DAILY VALUE TO MILLIGRAMS:
    The Daily Value for calcium is 1,000 milligrams.
    Look at the Nutrition Facts label and find the percentage of calcium in the product per serving. For example: 25%.
    Convert the percentage to a decimal: 25% = 0.25
    Multiply the decimal by 1000 to get the amount of calcium in milligrams: 0.25 x 1000 = 250mg (per serving).6
    Aim for >10% of calcium (100 mg) per serving to get a reasonable amount of calciumper serving.

TAKE HOME MESSAGES:

  • People who are recently diagnosed with celiac disease may have lactose intolerance.
  • There are several ways to test for lactose intolerance - a trial at home or the the hydrogen breath test are the most common. Less common is the lactose tolerance test.
  • A low-lactose diet, rather than a strict lactose-free diet, is generally appropriate when someone is diagnosed with lactose intolerance.
  • For many, the tolerance to lactose is likely to normalize eventually as treatment of their celiac disease can lead to recovery of their lactase activity. This often allows most or all gluten-free dairy products to be reintroduced.
  • You may be advised to take calcium and vitamin D supplements, particularly if you are following a low-lactose diet that does not provide enough calcium and vitamin D.
  • As always seek guidance from your doctor or dietitian when making any changes in your diet to avoid neglecting any significant nutrients.

RESOURCES FOR YOU:

Office of Dietary Supplements. National Institutes of Health. Dietary Supplement Fact Sheet: Calcium. http://ods.od.nih.gov/factsheets/calcium

Office of Dietary Supplements. National Institutes of Health. Dietary Supplement Fact Sheet: Vitamin D. http://ods.od.nih.gov/factsheets/vitamind 

USDA National Nutrient Database. 
https://ndb.nal.usda.gov/ndb/nutrients/index

References:

  1. Raymond N. The Gluten-Free Vegetarian. In Real Life with Celiac Disease: Troubleshooting and Thriving Gluten-Free . Eds. Dennis M, Leffler D. AGA Press. Bethesda, MD, 2010.
  2. Lactose-restricted diet. Nutrition Services, Beth Israel Deaconess Medical Center, ©2008
  3. Dennis M, Barrett J. Malabsorption of Fructose, Lactose, and Related Carbohydrates. In Real Life with Celiac Disease: Troubleshooting and Thriving Gluten-Free . Eds. Dennis M, Leffler D. AGA Press. Bethesda, MD, 2010.
  4. Lactose Intolerance. National Digestive Diseases Information Clearinghouse.http://digestive.niddk.nih.gov/ddiseases/pubs/lactoseintolerance/ . Accessed May 2, 2011.
  5. 2010 Dietary Guidelines Encourage Americans to Eat More Low-Fat and Fat-Free Dairy Foods. National Dairy Council. http://multivu.prnewswire.com/mnr/nationaldairycouncil/47923/ . Accessed May 2, 2011.
  6. American Dietetic Association. Evidence Analysis Library Toolkit on Celiac Disease. Food Sources of Calcium. Accessed 9/21/2011.

Revision Date: 8-23-12 
Author: Melinda Dennis, MS, RD, LDN and Annie Peer 
Editors: Suzanne Simpson, RD and Daniel Leffler, MD, MS

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