What to eat if you have lactose intolerance?

Lactose is a carbohydrate, and more particularly a disaccharide, composed of a glucose molecule linked to a galactose molecule. It is exclusively found in milk and its derivatives (yogurts, cheeses, cakes, ice creams, certain drinks, ready meals, sauces). It is one of the “fermentable sugars” also called “FODMAPs” (Fermentable Oligosaccharides Disaccharides Monosaccharides and Polyols). Lactose participates in the balance of intestinal flora because colonic bacteria transform it into lactic acid. This acidity produces a slight antiseptic effect.

To be absorbed, this disaccharide must be digested by an enzyme, lactase (beta-galactosidase), which releases galactose and glucose. This galactose is essential for the formation of galactocerebrosides, which are essential in the child's brain. This is why lactase is highly expressed in the infant's small intestine. Lactase is also very present in infants for breastfeeding reasons, because breast milk is very rich in lactose. His expression is genetically programmed to decrease in childhood in most mammals, in particular because breastfeeding is not supposed to continue from this period.

Lactose intolerance can be confused with cow's milk protein allergy (CMPA).

• Cow's Milk Protein Allergy (CMPA) : it is the result of an abnormal reaction of the immune system towards cow's milk proteins. It is mainly found in young children. It is mediated by immunoglobulin E (IgE) which is the immediate form of the allergy, or not mediated by IgE (delayed form). This causes allergy symptoms that can range from skin rashes to anaphylactic shock. It can also cause digestive symptoms like diarrhea and vomiting, which is why it is confused with lactose intolerance. The diagnosis is made via the Prick Test, mini allergen deposits on the forearm to see if there is an allergic skin reaction or not.

• Severe lactose intolerance or alactasia : unlike allergies, intolerance does not involve a reaction from the immune system, it is rather an enzymatic problem. Lactose intolerance is defined as (digestive) discomfort linked to a consumption of lactose that exceeds a person's own capacity for digestion and tolerance. This intolerance is due to alactasia (total or almost absence of lactase) which does not allow lactose to be digested optimally. The diagnosis most often uses a lactose consumption test. In general, a dose of 20 g of lactose is given on an empty stomach (equivalent to half a liter of milk) with measurement of exhaled hydrogen. The higher the level of hydrogen exhaled, the less efficient lactose digestion is.

• Partial lactose intolerance or hypolactasia : this is the main source of confusion with severe lactose intolerance. Indeed, few patients have true (severe) lactose intolerance, but often have hypolactasia (moderate intolerance). It is characterized by the decrease in lactase activity which is genetically programmed until 8-12 years of age, following the neonatal period and breastfeeding. It is estimated that 70% of the adult population has hypolactasia, which is often asymptomatic. There are also partial forms of intolerance, following an episode of gastroenteritis for example.

If a quantity of lactose greater than the tolerance threshold is ingested, it is not digested. Thus, it exerts an osmotic effect in the small intestine (water call and acute osmotic diarrhea) and can reach the colon, where it is fermented by the microbiota via the production of volatile fatty acids and gases (H2, CO2 , methane). This results in bloating and abdominal pain. This pathogenesis is common to FODMAPs, which is why lactose intolerance can also be confused with FODMAP intolerance.

In the majority of cases of lactose intolerance, we speak rather hypolactasia what true intolerance. However, many misnomers lead us to speak of lactose intolerance, and often wrongly. On average, symptoms of bloating are noticed from an ingestion of approximately 12 g of lactose (240 mL of milk). In this case, it is recommended to avoid only milk in drinks, since cheeses and yogurts are generally well tolerated in cases of hypolactasia. Indeed, yogurts provide their own lactase thanks to their milk bacteria and cheeses are quite low in lactose. However, in rare cases there is a total alactasia, where the presence of lactase is very low, or even zero, and where strict exclusion of lactose is inevitable. The latter refers to “true intolerance”, also called severe intolerance.

In the majority of cases, patients complain:

• short term : abdominal pain, diarrhea, vomiting, edema and gas in the hours following ingestion of milk.

• medium term : weight loss or weight stagnation.

Malabsorption of a small amount of lactose of the order of a few grams is generally asymptomatic. Additionally, these symptoms can appear up to 48 hours after ingesting lactose. It can therefore be difficult to identify the cause of the symptoms. Also, these clinical signs are dependent on several factors, including the dose of lactose, residual lactase expression, simultaneous ingestion of other food components, intestinal transit time and gut microbiota composition.

Whether in case partial intolerance (hypolactasia) Or severe intolerance (alactasia), drinking milk is generally very poorly absorbed in cases of intolerance. Indeed, it is the food richest in lactose with an average content of 4.5 to 5 g per 100 mL of milk. Additionally, malabsorption is influenced by the flow rate of lactose arriving, whether as a function of time or the amount of lactose. In this way, milky liquids are very poorly tolerated because they reach the intestines quickly, whether they are cow's milk, goat's milk or sheep's milk.

Indeed, despite the fact that popular beliefs tend to say that goat's and sheep's milk are better tolerated, there is still no no scientific consensus clear about this. Beliefs relate in fact to their slightly lower lactose content (4.2 g of lactose for goats and 4.5 g for sheep, compared to 4.7 g for cows), but also to a fatty acid content. short and medium chain fatty acids more digestible than long chain fatty acids from cows, which are less digestible. However, no study has yet proven this benefit.

Finally, it is estimated that consumption of more than 12 g of lactose (240 mL of cow's milk = a full glass) is not tolerable in the event of partial intolerance. It is therefore possible to consume cow's, goat's and sheep's milk, but it must be limited. However, in the event of severe intolerance, milk drinks should be completely excluded from the diet.

We recommend you :

• to avoid milk with an empty stomach and in large quantities, because milk is better tolerated if consumed with other solid foods (chocolate, foods rich in fiber). Indeed, consuming lactose with solid foods rich in fiber improves lactose tolerance. These fibers, and in particular prebiotics, seem to have an overall positive relationship on the intestinal microbiota of people with lactose intolerance.

• to consume maximum 240 mL of milk in drink per day (a full glass) which is the average content tolerated by hypolactasic patients.

• to limit skimmed milk, favoring whole milk or semi-skimmed in case of partial intolerance, because it is richer in lipids and is therefore better tolerated via a slower gastric emptying. Indeed, malabsorption being influenced by a rapid flow of lactose arriving, lipids will help slow down this flow by slowing down gastric emptying.

• in case of moderate intolerance and after the symptoms disappear, it is possible to test and increase lactose intake from 5 g to 5 g (from 100 mL to 100 mL of milk) to try to reintroduce it. Indeed, milk remains a primary source of calcium, and lactose, an interesting source of galactose for infants.

• to alternate or replace this consumption with vegetable drinks with the aim of maintaining a certain lifestyle habit (breakfast bowl), while waiting for the gradual re-increase of lactose in the event of partial intolerance.

Yogurts are generally very well tolerated. In fact, they have nearly a billion milk bacteria possessing their own lactase, which allows lactose to be digested directly in the intestines. This therefore does not induce fermentation and therefore symptoms of intolerance. In addition, unlike skimmed milk, they induce slower gastric emptying and are thus better tolerated.

We recommend you :

• to test your tolerance to yogurts, because studies have shown tolerance to 2 yogurts per day in the event of partial intolerance.

• to consume, if possible, once a day a natural yogurt for its calcium intake. In addition, it helps rebalance the intestinal flora thanks to the milk bacteria it contains.

On average, cottage cheese has around 3 g of lactose per 125 g pot, and kefir has 3.58 g of lactose per 100 g. However, they are generally very well tolerated. Indeed, just like yogurts, cottage cheeses and kefir contain milk bacteria with their own lactase, which allows optimal lactose digestion.

We recommend you :

• to test your tolerance to cottage cheese, as a snack or at the end of a meal.

• to consume it preferably with a solid food to further facilitate tolerance.

• if cottage cheeses trigger symptoms of intolerance, it is preferable to remove them and test their tolerance again after the symptoms disappear. To do this, we gradually increase the weight: 20 g of fromage blanc, then 40 g, then 60 g, etc.

Most of these cheeses are very well assimilated because they do not do not contain lactose, or even very little and in trace amounts. It is therefore possible to consume them in small quantities.

We recommend you :

• to choose the following cheeses low in lactose: emmental, gruyère, parmesan, camembert, brie, tomme, comté.

• to consume maximum 30 g of cheese per day (approximately 1 serving), based on ANSES recommendations.

• If these cheeses trigger symptoms of intolerance, it is preferable to remove them and test their tolerance again after the symptoms disappear. To do this, we gradually increase the weight: 10 g of cheese, then 20 g, then 30 g.

These cheeses are quite rich in lactose, with on average between 2.5 and 4.1 g of lactose per 100 g of finished product. However, the doses consumed are regularly low and they are generally consumed with bread, a solid food improving lactose tolerance. Finally, just like yogurts and cottage cheese, fresh cheeses contain numerous milk bacteria that digest lactose.

We recommend you :

• to test your tolerance for fresh cheeses: cottage cheese (Saint-Môret®,Philadelphia®, approximately 3.5 g of lactose per 100 g), faisselle (3.6 g of lactose), petit-suisse (3 g of lactose).

• to consume these fresh cheeses with bread and, if possible, wholemeal bread which is rich in fiber.

• If these cheeses trigger symptoms of intolerance, it is preferable to remove them and test their tolerance again after the symptoms disappear. To do this, we gradually increase the weight: 10 g of cheese, then 20 g, then 30 g.

Processed cheeses (gruyere cream, aperitif cubes, Kiri®), as well as mascarpone, ricotta and bush, are cheeses quite rich in lactose. In fact, they contain on average between 2 and 5 g of lactose per 100 g of cheese. In this way, they can be a source of intolerance. However, they are tolerated if we base ourselves on the recommendations of 30 g of cheese maximum per day set by ANSES (National Agency for Food, Environmental and Occupational Health Safety). In addition, these foods can be consumed with solid foods or foods rich in fiber such as bread or savory recipes, which optimizes their tolerance.

We recommend you :

• of test your tolerance with processed cheeses and avoid excesses: gruyere cream, Kiri®, aperitif cubes, Meaux brie cream, Société Crème®.

• to split the doses if consumed, in order to avoid ingesting too much lactose at one time.

• to consume maximum 30 g of mascarpone (4 g of lactose per 100 g), ricotta (2.25 g of lactose) or bush (4.3 g of lactose) per day.

• to consume these cheeses with solid or fiber-rich foods to improve their tolerance (bread, wholemeal bread, pasta, wholemeal pasta, etc.).

• If these cheeses trigger symptoms of intolerance, it is preferable to remove them and test their tolerance again after the symptoms disappear. To do this, we gradually increase the weight: 10 g of cheese, then 20 g, then 30 g.

Butter and crème fraîche are fats that contain lactose (0.83 g of lactose per 100 g of butter, 2.65 g of lactose per 100 g of crème fraîche). Again, they are tolerable because their amount of lactose is quite low compared to the amount of finished product consumed. In fact, the average portions of butter are around 10 to 20 g per meal, and the portions of crème fraîche around the 30 to 40 g per meal.

We recommend you :

• to consume a maximum of 30 g of butter and 50 g of crème fraîche per day, while favoring cooking and seasoning oils which do not contain lactose: rapeseed oil, olive oil, camelina oil, walnut oil, linseed oil.

Lactose is very present in the food industry and particularly in prepared meals which use sauces and dressings. It can also be hidden in margarine, cold meats, biscuits or even chocolates. However, lactose levels can be quite low, which is why they can be tolerated.

We recommend you :

• of read labels the following industrial products: cakes, ice cream, rice pudding, cream, flan, certain drinks, ready meals, sauces, milk chocolate and white chocolate.

• to test and, if necessary, limit your consumption of industrial preparations containing milk such as pastries and pastries.

• to promote the achievement of homemade dishes. In fact, industrial products do not have beneficial effects on health, but rather on lifestyle and taste.

• if these preparations trigger symptoms of intolerance, it is preferable to remove them and test their tolerance again after the symptoms have disappeared.

Alactasia is characterized by the body's inability to synthesize lactase, this is why it is defined as severe intolerance or “true intolerance”. Indeed, at the medical level, lactose intolerance rather refers to alactasia, and not hypolactasia. In this scenario, no source of lactose is tolerated and this leads to serious diarrhea quickly leading to dehydration. The latter leads to malnutrition and can lead to death. It is therefore essential to avoid lactose, and it will be impossible to reintroduce it into the diet. The management of alactatic patients is therefore essential and is based on the following principles:

• Medical monitoring to detect this intolerance. The doctor will order a respiratory test with measurement of exhaled hydrogen in order to establish, or not, the diagnosis of lactose intolerance of the alactase type.

• Essential nutritional monitoring with a dietitian nutritionist or a nutritionist doctor.

• Nutrition education on lactose, lactose sources and food labels.

• Exclusion of all sources of lactose : milk, cheeses, yogurts, butter, creams, industrial preparations, industrial milk products (milk chocolate, milk biscuits, etc.).

Nowadays, great efforts have been made by the agri-food industries to offer a wide range of lactose-free products. This is why consumers have seen lactose-free milk (Gallia Expert Digital plus baby, Matin Léger), lactose-free yogurts and lactose-free cheeses appear on the shelves. In this way, there is almost no deprivation, unlike in the previous decade. However, there are no regulations on the maximum content for a “lactose-free” label. Studies on certain lactose-free products have nevertheless shown that on average the lactose content is estimated at 10 ppm (parts per million = 10 mg/L). Thus, these products will be very well tolerated in cases of hypolactasia, but not in case of total alactasia.

Consumers have also witnessed the emergence of vegetable drinks having the same texture as milk (vegetable drinks made from soya, almonds, spelled, etc.). Wrongly named “plant milks”, plant-based drinks do not have the same nutritional values than animal milks, although the texture and taste are similar. It may nevertheless be wise to move towards these plant-based drinks in order to maintain a certain lifestyle around milk (breakfast bowl), despite a much lower calcium level than animal milk. The latter are generally made from soya, almonds, spelt, or even rice, and it is wise to vary the sources. In this way, they can be an interesting replacement for those who are lactose intolerant because their content of this disaccharide is zero.

Thus, as part of an exclusion of dairy products, it is recommended to provide food sources of calcium in order to compensate for the potential deficits linked to this exclusion. Therefore, it is preferable to move towards mineral water rich in calcium such as Hépar (549 mg/L), Courmayeur (576 mg/L) or Contrex (468 mg/L). In terms of food, it is advisable to optimize your intake of meats (especially white pudding), pisces (sardines specifically with their bones) and eggs, which are animal products rich in calcium. THE green vegetables are also a more than reasonable source in terms of calcium, notably spinach (240 mg of calcium per 100 g), raw watercress (101 mg) and most cabbage (50 mg on average). Finally, certain oilseeds are rich in calcium such as sesame seeds (962 mg of calcium per 100 g), almonds with skin (260 mg) and chia seeds (631 mg). In addition, even if the weights are quite low, it may be wise to opt for spices and aromatic herbs rich in calcium: ground savory (2130 mg of calcium per 100 g of savory), cinnamon (1000 mg of calcium ), cumin seeds (931 mg of calcium) and curry (525 mg of calcium).

No, that's not relevant. It must be adapted only to those who need it and therefore those with severe lactose intolerance (alactasia). Indeed, even in cases of moderate intolerance (hypolactasia), it is recommended to reintroduce dairy products. Otherwise, it is essential to ensure that you meet your calcium needs through other sources or supplementation if necessary.

Indeed, lactose is only present in dairy products which are the main source of calcium. in our western food model. It is true that certain foods are richer in calcium than dairy products, notably baking powder (8960 mg per 100 g), aromatic herbs and spices. However, these foods are consumed in too small quantity in food to cover our needs. In fact, a full glass of milk (284 g of calcium) and a 30 g portion of cheese (on average 170 g of calcium) can achieve almost half (454 g of calcium) of the daily calcium requirements. The latter are estimated by ANSES at 1000 mg per day before the age of 25 and at 950 mg per day after the age of 25. However, it is important to know that vegetable calcium is generally as well or better absorbed than dairy calcium. Indeed, calcium from dairy products is absorbed around 32% according to certain sources, while it is around 50 to 60% for certain plants such as Chinese cabbage, broccoli and kale. In this way, even if dairy products remain an important source of calcium in the modern diet, their consumption can be accompanied or replaced (depending on diets) by equivalents rich in calcium to meet daily needs.

In this way, following a lactose-free diet can involve risks of deficit or even deficiency in calcium, which would be dramatic for bone, muscle and nerve health. Indeed, calcium is one of the most important minerals in the body, if not the most important. Its main roles are as follows:

• Bone mineralization : it constitutes the framework of the bone with phosphorus. Bone renewal requires 700 mg of calcium ion Ca2+ per day in adults.

• The nervous system : it allows the release of neurotransmitters.

• Muscle contraction : it binds to molecules called troponin and tropomyosin, it thus changes its conformation, which frees the myosin binding site. The latter is a fundamental protein in muscle contraction mechanisms.

The main consequences of a calcium deficit or deficiency are as follows:

• Tremors, cramps, tetany, heart rhythm disturbances.

• Decreased neuromuscular excitability, growth and weight delay.

• Bone fractures, osteoporosis (guide to osteoporosis and diet), osteomalacia, osteoarthritis (guide to osteoarthritis and diet), rickets (bone disease characterized by “X” shaped legs).

The tolerance threshold is estimated around 12 g of lactose per day.

Breakfast :

• Coffee or tea or bowl of lactose-free milk
• Bread toast with butter
• One or two clementines

Lunch :

• Fennel salad with rapeseed oil
• Pan-fried white pudding
• Couscous with vegetables
• Natural yogurt

Snack :

• Muesli or oatmeal
• Cottage cheese
• A banana

Dinner :

• Celery mayonnaise
• Bolognese pasta with carrots
• Chocolate mousse

The lactase level is zero, so there is no lactose tolerance. The exclusion of foods containing lactose is inevitable (milk, cheese, yogurt, butter, industrial preparations containing powdered or whole milk, etc.).

Breakfast :

• Coffee or tea or bowl of almond vegetable drink
• Breakfast cereals
• An apricot

Lunch :

• Asparagus
• Pan-fried sardines
• Quinoa
• Spinach
• An Apple

Snack :

• A few almonds with skin
• Bread buns with fig jam

Dinner :

• Tomatoes in rapeseed oil
• Homemade green cabbage soup
• Potato omelette without milk
• Some strawberries

• Be followed by a doctor and a dietitian nutritionist in case of true intolerance. This diet must exclude all traces of lactose from the diet, so it is wise to seek help from a health professional. In addition, it is recommended to carry out a breathing test with measurement of exhaled hydrogen in order to detect lactose intolerance or not. In any case, it is best not to do not exclude foods containing lactose from the diet if the diagnosis of intolerance has not been made.

• Always under the supervision of a doctor or a dietitian-nutritionist, and in case of partial intolerance, it is possible to estimate your tolerance threshold following a 3-phase protocol. The first phase avoiding dairy products lasts two weeks and helps reduce symptoms. Then, the second phase of tolerance testing consists of gradually increasing the quantities of lactose to identify the threshold for triggering symptoms. Finally, the third phase of making the transition to a permanent diet with tested and well-tolerated foods.

• It is also important to meet your vitamin D needs which actively participates in intestinal absorption and the fixation of calcium on the bones. In addition, it is recommended to have a daily physical activity approximately 15 to 30 minutes in order to promote bone synthesis.

• In case of partial intolerance, it seems that food supplements rich in lactase can help increase the lactose tolerance threshold. This would help avoid digestive disorders caused in the event of a “discrepancy”. Do not hesitate to discuss it with your doctor.

• A diet that is too acidic (red meats, cheeses, cereals) increases the risk of leaking calcium into urine. To limit this phenomenon, it is recommended to avoid excess acidifying foods and to combine their consumption with that of alkalizing foods (vegetables, spices, fruits).