Laura Manning is a Clinical Dietitian at The Susan and Leonard Feinstein Inflammatory Bowel Disease Clinical Center at Mount Sinai. Today, she is discussing the basics of lactose intolerance.   

THE BASICS

According to the 2020 Dietary Guidelines for Americans, it is recommended that adults consume 3 servings of low fat or fat free dairy products daily as part of a healthy diet.[i] Dairy products consist of milk, yogurt, cheese and kefir and supply the primary source of calcium for Americans. Calcium is associated with improved bone health and is especially important to consume during childhood and adolescence, as bone mass is being built at this time.[ii] In adults, dairy intake is associated with lower blood pressure[iii] and a reduced risk of cardiovascular disease[iv] and type 2 diabetes. [v],[vi]

One 8-ounce glass of milk from cows, sheep and goats consists of carbohydrates (12g of lactose) for energy, protein (6-8g of casein) for growth, fat for brain health, and the all-important calcium for bone development. The fat content can vary widely as there are a variety of milk choices on the market; from milk that contains zero fat (skim) to milk with a full fat content (whole). Additionally, dairy milk is comprised of phosphorous, potassium, magnesium, vitamins A, D, B12, niacin and riboflavin. It is a widely consumed beverage and supplies us with important nutrients across the lifespan.

Fact: Most people are born with the innate ability to digest dairy, as lactose is found in breast milk. However, the ability to digest dairy milk may become more and more difficult as we get older. It is estimated that about 30 million Americans are lactose intolerant by the age of 20.[vii]

WHAT CAUSES LACTOSE INTOLERANCE?

We typically digest milk with an enzyme (lactase) found in our small intestine. Lactase cleaves the sugar from milk into glucose and galactose to make it more digestible. This product is then absorbed into the bloodstream to be used for energy. However, some people may not produce adequate amounts of the lactase enzyme and, as a result, may experience symptoms such as gas, bloating and diarrhea soon after consuming milk products. Low enzyme levels cause the lactose to remain intact as it travels to the colon, where it attracts bacteria and begins to ferment. The uncomfortable symptoms associated with an intolerance are a result of this fermentation process.

TYPES OF LACTOSE INTOLERANCE

Primary lactose intolerance is the most common food intolerance in the world and is more prevalent among certain cultures. It is the most common form of the disorder and is often founds in people of African, Asian, Hispanic, Mediterranean and southern European descent. Secondary lactose intolerance may arise due to an injury, surgery or illness where inflammation or changes in the small intestinal structures occur. Crohn’s and Celiac disease are the two most common intestinal diseases associated with having lower levels of lactase production. This is a very frequent topic that I discuss with patients at the IBD Center at Mount Sinai. Lactose intolerance can also present during a Crohn’s or Ulcerative Colitis flare.

There is a small subset of people who may have intolerance to casein, the protein component in milk. Of the 6-8 grams of casein in milk, 2-3 grams are known as beta casein and come in two forms, known as A1 and A2. Most cows contain an even distribution of A1 and A2, but before milk became industrialized, most cows were producing A2. A2 milk may be an easier to tolerate form of milk and you will see it beginning to pop up in the dairy aisle.

YES, THERE ARE LACTOSE-FREE CHEESES!

If you have lactose intolerance, it does not mean that you should avoid all dairy products. This is a common misconception and can lead people to miss out on the important nutrients that dairy products provide. There are varying levels of lactose in dairy products, ranging from 12 grams in a glass of cow’s milk to 1 gram in a serving of aged cheddar cheese. Most people with lactose intolerance can tolerate up to 12g of lactose in one sitting, and approximately 18g of lactose if spread throughout the day.[i] However, some individuals may need the help of an added enzyme to assist with their digestion. Over-the-counter enzyme pills and chewables consumed at the time of meal will help break down the lactose, making it more enjoyable to eat without all of the gas and bloating that typically accompanies digestion. It may even be possible to train the body to tolerate lactose if given small amounts over a period of time.[ii] Additionally, having lactose-containing dairy as part of a meal, rather than on an empty stomach, will further help aid in the digestion process.[iii]

On a Low FODMAP diet, lactose is one of the fermentable sugars that should be lessened in the elimination phase of the diet. You are able to consume dairy products on the Low FODMAP diet, but the lactose content should be small. Take a look at the Nutrition Facts label. The lactose will be considered ‘low’ if there are 4 grams of carbohydrate or less per serving. Just be sure, keep it to the serving size indicated and have one single serving per meal. Low lactose cheeses permitted with this diet include aged cheeses such as cheddar, Swiss and Parmesan. Greek yogurt is low lactose as well, but try stick to the unflavored/original yogurts and add fruits for natural sweetness. You’ll be happy to know that butter is almost completely lactose free! You can also select dairy products that contain the lactase enzyme in them. Dairy can be challenging to tolerate for many people, but following a few guidelines on food choice and quantity allows you to keep it in your diet and reap all the nutritional benefits dairy has to offer.

Resources that can help you:

Mount Sinai Make an appointment at the Feinstein IBD Clinical Center here or contact the office at 212.241.8100.

Epicured For exceptional low FODMAP, IBD-friendly prepared meals delivered right to your door, visit our menu.

DOWNLOAD the Low FODMAP Cheeseboard infographic!

________________

DISCLAIMER: Mount Sinai is an investor in Epicured. This material is for informational purposes only, and Mount Sinai makes no representation or guarantee as to any results or experience with Epicured. You should consult with your physician before using a dietary program such as Epicured. Mount Sinai employees do not receive material benefit from endorsing or recommending Epicured. 

Laura Manning is not employed by Epicured. Laura is a full-time employee of the Mount Sinai Health System and receives no compensation, monetary or otherwise, from Epicured. 

REFERENCES: 

[1] Dietary Guidelines for Americans 2015-2020. Recommended amount of dairy to be consumed daily for Americans 9 years and older. www.choosemyplate.gov. accessed June 8, 2018.

[1] Weaver CM, et al. The National Osteoporosis Foundation’s position statement on peak bone mass development and lifestyle factors: a systematic review and implementation recommendations. Osteoporosis Int. Published online Feb 8, 2016.

[1] Machin DR, Park W, Alkatan M, Mouton M, Tanaka H. Effects of non-fat dairy products added to the routine diet on vascular function: a randomized controlled crossover trial. Nutr Metab Cardiovacs Dis. 2015;25(4):364-369.

[1] Dalmeijier, GW, et al. Dairy intake and coronary heart disease or stroke: A population-based cohort study. Int J Cardiol 2013;167:925-929.

[1] Margolis, KL, et al. A Diet High in Low Fat Dairy Products lowers diabetes risk in in post menopausal women. J Nutr 2011;141:1969-1974.

[1] Sluijs I, et al. The amount and type of dairy product intake and incident of type 2 diabetes: results from the EPIC-InterAct Study. Am J Clin Nutr 2012;96:382-390.

[1] Lactose intolerance. Statistics accessed from the web June 6th, 2018. U.S. National Library of Medicine. https://grh.nlm.nih.gov/condition/lactose-intolerance#statistics.

[1] Corgneau M, Scher J, et al. Recent advances on lactose intolerance: Tolerance thresholds and currently available answers. Crit Rev Food Sci Nutr. 2017;57(15):3344-3356.

[1] Pribila BA, Hertzler SR, Martin BR, Weaver CM, Savaiano DA. Improved lactose digestion and intolerance among African-American adolescent girls fed a dairy rich diet. J Am Diet Assoc. 2000; 100(5):524-8.

[1] Shaukat A, Levitt MD, et al. Systemic Review: Effective management strategies for lactose intolerance. Annals Int Med. 2010; 152(12):797-803.

 

 

 

 

 

 

 

 

Renee Cherkezian, RN is a nurse-turned-chef and co-founder of Epicured.

Chef Renee preps the Za’atar Chicken. Credit: Ben Fink Productions

In my house growing up, we would put za’atar on just about everything. Za’atar is a traditional Middle Eastern & Mediterranean spice blend and one of my very favorite flavors. Food carts and lunch joints across the Middle East use it for labneh, a thick and tangy sheep’s milk yogurt. In Lebanon, the traditional salad of tomatoes and ripped pita called fattoush is topped with a dusting of za’atar.

The za’atar you buy in the spice shop is usually a blend of different herbs. According to Lior Lev Sercarz, the master spice blender from the spice shop La Boîte, the most traditional elements of a za’atar blend are its namesake za’atar leaves along with sumac, sesame seeds and thyme.

When creating our new Za’atar Chicken, we looked all over the perfect blend. Which za’atar tasted best dry? Which za’atar tasted the best with extra virgin olive oil? Most importantly, which za’atar best complimented the chicken’s marinade of lemon zest, lemon juice, garlic infused olive oil, sumac, parsley black pepper?

I tested 7 different za’atars before finding one that met this standard. La Boîte’s blend was simply the best, hands down. The Za’atar Chicken is one of my favorite new creations. It’s healthy, fresh, and it takes me back to my childhood when I was first inspired to cook. I hope you enjoy.

The Za’atar Chicken with Quinoa Tabbouleh. Credit: Ben Fink Productions

Laura Manning is a Clinical Dietitian at The Susan and Leonard Feinstein Inflammatory Bowel Disease Clinical Center at Mount Sinai.

Inflammatory Bowel Diseases (IBD) such as Crohn’s disease and ulcerative colitis are believed to be caused by a combination of genetic predisposition and alterations in the gut microbiota. These disorders are on the rise in industrialized areas like North America and Western Europe [1], forcing scientists to reconsider the role of modern diets in the development and management of these diseases. Indeed, our gut bacteria look quite a bit different from our ancestors’ as we eat more and more processed foods to help us keep up with our busy lives and to allow us to prepare foods quicker and easier.

Can Food Choices Descrease Your IBD Risk?

Studies show that certain dietary patterns may put people at greater risk for IBD [2]. For example, having a low-fiber, high-fat diet may increase inflammation and cause disease relapses. This is typical of a diet with a lot of processed foods. In contrast, a diet high in soluble fibers, fruits and vegetables and low in saturated fat may be beneficial to our microbiome and have anti-inflammatory properties. [3,4]

Our Low FODMAP Lemon Rosemary Chicken meets many of Laura’s “IBD-friendly” requirements. Photo credit: Ben Fink Productions for Epicured.

FOOD AS IBD TREATMENT

In addition to conventional medication focused on modifying the immune-inflammatory pathways in the gastrointestinal (GI) tract, diet can also play an essential role in the management of IBD, especially for patients with a lot of unpleasant GI symptoms such as diarrhea, urgency and abdominal cramps. Unfortunately, there is not enough scientific evidence to suggest that there is a “silver bullet” diet for IBD, or, for that matter a single diet approach that can take someone with IBD from a very severe flare-up all the way down to remission (i.e. no signs of inflammation at all).

The good news is that in academic medical centers across the world (including at Mount Sinai where I practice), there are studies underway to look at the link between IBD and a variety of diets, including, of course, low FODMAP.

Low FODMAP & IBD: What We Know Today

There is very strong evidence showing the benefits of the Low FODMAP diet for managing symptoms in patients with Irritable Bowel Syndrome (IBS), a much more common disorder of gut-brain dysregulation with many of the same symptoms as IBD [5].  We are now seeing that the diet can help manage symptoms in patients with IBD as well, especially when they’re in remission. Here’s why:

Often times, a person with IBD can be technically in remission (a healed intestinal tract) but continue to experience symptoms that mimic an IBD flare-up. This is known as IBD with IBS overlay and it is extremely common, affecting 40-60% of IBD patients. High FODMAP foods can trigger IBS symptoms in people with IBD and make them feel like they are experiencing a flare-up [6]. In fact, in a recent study, the Low FODMAP diet was shown to lower symptoms like gas, bloating, diarrhea, nausea and fatigue [7,8] in patients with IBD.

FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) are hard to digest sugars which pass through the small intestine without being properly broken down by enzymes. Once these sugars reach the colon, they cause an osmotic shift bringing more water into the lumen which causes all the potential unpleasant side effects of pain, bloating and diarrhea. Additionally, the bacteria ferment (think of brewing beer), and the residual FODMAPs give off gas, as if there wasn’t enough to manage!

“OK… SO WHAT CAN I EAT?”

The most common question patients with IBD ask me is “what can I eat?” My goal is to help patients find ways to eat that will allow them to manage symptoms and feel like they are in control. That’s where the low FODMAP diet becomes so useful. A FODMAP elimination and reintroduction process can be a life-changing tool for IBD patients to identify the triggers that add to their daily stress. We know food alone does not cause IBD but many patients will begin to notice “trigger foods” that increase their symptoms of gas, bloating, and diarrhea. The best way to identify your trigger foods is to simply keep a journal of what you eat. Note if there are changes that occur in our bowel function when certain foods are eaten more than others.

IT’S NOT: ‘ONE SIZE FITS ALL’

Don’t get frustrated. What works for one person with IBD may not work for another. This is one of the many challenges that I have as a dietitian working with patients at the Feinstein IBD Center at Mount Sinai. Having worked with patients with IBD for over 15 years, I have seen many different diet therapies work and not work, and I must tailor suggestions to each individual person.

Food is a very important topic because it evokes a lot of emotion in people. People with IBD must carefully think about what to eat and the timing of their meals and if I can offer suggestions that help ease this stress, then I can successfully increase their nutrition, allow people to eat comfortably at work and at gatherings and lessen anxiety that commonly accompanies mealtime. Food is a large part of our culture as well as a basic human need and patients with IBD welcome guidance to help manage their disease and lead the healthiest life they can.

Resources that can help you:

Mount Sinai Make an appointment at the Feinstein IBD Clinical Center here or contact the office at 212.241.8100.

Epicured For exceptional low FODMAP, IBD-friendly prepared meals delivered right to your door, visit our menu.

IBD 101 Here are the basics: IBD (including Crohn’s Disease and Ulcerative Colitis) is an autoimmune condition where the digestive tract becomes inflamed and forms ulcerations that can cause a wide range of symptoms including frequent bowel movements, weight loss, and vitamin deficiencies. The gastrointestinal (GI) tract contains harmless bacteria that aids in digestion and the metabolism of vitamins. In people with IBD, the body mistakes the bacteria as foreign invaders and cells travel from the blood system to the GI tract, creating an inflammatory response and causing a variety of GI symptoms [9]. IBD can also affect your eyes, skin and joints and can have a profound impact on daily life.

________________

DISCLAIMER: Mount Sinai is an investor in Epicured. This material is for informational purposes only, and Mount Sinai makes no representation or guarantee as to any results or experience with Epicured. You should consult with your physician before using a dietary program such as Epicured. Mount Sinai employees do not receive material benefit from endorsing or recommending Epicured. 

Laura Manning is not employed by Epicured. Laura is a full-time employee of the Mount Sinai Health System and receives no compensation, monetary or otherwise, from Epicured. 

REFERENCES: 

[1] Molodecky, N.A.; Soon, I.S.; Rabi, D.M.; Ghali, W.A.; Ferris, M.; Chernoff, G.; Benchimol, E.I.; Panaccione, R.; Ghosh, S.; Barkema, H.W.; et al. Increasing incidence and prevalence of the inflammatory bowel diseases with time, based on systematic review. Gastroenterology 2012, 142, 46–54.

[2] Hou JK, Abraham B, El-Serag H. Dietary intake and risk of developing inflammatory Bowel disease: a systematic review of the literature. Am J Gastroenterol 2011;106:563–73.

[3] Brown, K.; DeCoffe, D.; Molcan, E.; Gibson, D.L. Diet-induced dysbiosis of the intestinal microbiota and the effects on immunity and disease. Nutrients 2012, 4, 1095–1119.

[4] Ananthakrishnan AN, Khalili H, Konijeti GG, et al. A prospective study of long-term intake of dietary fiber and risk of Crohn’s disease and ulcerative colitis. Gastroenterology 2013; 145:970–977.

[5] Schumann D, Klose P, Lauche R, Dobos G, Langhorst J, Cramer H. Low fermentable, oligo-, di-, mono-saccharides and polyol diet in the treatment of irritable bowel syndrome: A systematic review and meta-analysis. Nutrition, Jan 2018;45:24-31.

[6] Selina R Cox Alexis C Prince Clio E Myers Peter M Irving James O Lindsay Miranda C Lomer Kevin Whelan Fermentable Carbohydrates [FODMAPs] Exacerbate Functional Gastrointestinal Symptoms in Patients With Inflammatory Bowel Disease: A Randomised, Double-blind, Placebo-controlled, Cross-over, Re-challenge Trial Journal of Crohn’s and Colitis. Dec 2017; 11

[7] Zhan, Y.L.; Zhan, Y.A.; Dai, S.X. Is a low FODMAP diet beneficial for patients with inflammatory bowel disease? A meta-analysis and systematic review. Clin. Nutr. 2017.

[8] Prince AC, Myers CE, Joyce T, et al. Fermentable carbohydrate restriction (low FODMAP diet) in clinical practice improves functional gastrointestinal symptoms in patients with inflammatory bowel disease. Inflamm Bowel Dis 2016;22:1129–1136.

[9] What are Crohn’s and Colitis. http://www.crohnscolitisfoundation.org/what-are-crohns-and-colitis/what-is-crohns-disease/. Accessed from the web May 12, 2018.

MOROCCAN TAJINE IS BACK AT EPICURED AND BETTER THAN EVER!

Whatever your taste – chicken, lamb or veggies – our Tajine is for you!

This dish is inspired by recipes from Morocco and Northern Africa and served with a side of gluten-free quinoa.

Renee discovered this extraordinary dish on a visit to Marrakech. After feasting on chicken tajine with apricots and almonds, she savored the memory and created the ultimate low FODMAP version.

MAKE WAY FOR CHICKEN TAJINE!

This special low FODMAP dish replaces the sweet flavors of onion, honey, apricots & dates with garlic oil and sweeter veggies and low-FODMAP sugars. Our Tajine chicken is simmered with cumin, turmeric, cinnamon, cloves, ginger, and paprika… all great inflammatory, pro-digestion spices to help cleanse the liver.

It’s a tasty treat!


 ANTIBIOTICS & YOUR GUT

A recommended read from the New York Times! Learn about some of the latest thinking on the use of antibiotics in animals and its impact on our gut microbiome. Worth noting: all our meats are 100% antibiotic-free!


 

SOME POPULAR DISHES

SESEME CRUSTED WILD SALMON  order now>

TIKKA MASALA  order now>

THREE-SPICE TURKEY CHILI  order now>

 

DRAGON FRUIT ANTIOXIDANT SMOOTHIE  order now>

 


 FODMAP FAQs WITH OUR CONCIERGE DIETITIAN

By Carena Lowenthal

A FEW QUESTIONS WE GET ALL THE TIME!

  1.  What is a FODMAP?

FODMAP’s are a group of small chain carbohydrates than can be difficult to digest for many people.  They pass from the small intestine into the large intestine undigested where they can be fermented and pull water into the intestine.  They could cause bloating, cramps, diarrhea or constipation.  FODMAP stands for Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols.

Our Low FODMAP Cheat Sheet is a great thing to keep around! Here’s a printable one and one for your phone.

  1.  I see you have garlic oil in your recipes, I thought garlic wasn’t allowed on the low-FODMAP diet?

Correct, garlic is not allowed in the solid form.  However, garlic infused oil, is allowed.  It has a lot of the flavor without the FODMAP component.

  1.  How long do I have to follow a low-FODMAP diet?

Usually people are placed on this diet for 2-6 weeks for an elimination phase.  Then they would be testing the groups, in a methodically, proven way, to help determine where the intolerances lie.  Once you find out what you need to avoid, you can go back to an appropriate diet.  Epicured is 100% low-FODMAP so you can use our service during the Elimination Phase as well as to fill in after you’ve gone back to your new plan.

FODMAP ELIMINATION, FODMAP RE-INTRODUCTION, AND HOW EPICURED FITS IN

Have more questions for Carena? Email concierge@getepicured.com! We’re here to help.

 


 

 

MARK JUNE 14TH… EPICURED IS CATERING THE JUNTO HEALTH CONFERENCE(LINK: https://juntohealth.org/)