Milk is Not for Every Body

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Chapter 1 -- If 3,000,000,000 People in the World Are Lactose Intolerant, Then Why Aren't We Rich?

1. Rolling Stone: "Hot Disorder: Lactose Intolerance," Rolling Stone, 5/14/92, p. 92.

1. $100 million barrier: Dairy Ease promotional literature.

2. 70%: "Recent Advances in the Management of Lactose Intolerance," Dennis A. Savaiano & Catherine Kotz, Contemporary Nutrition, 1988:13(9,10):1-4, p. 1.

2. 10,000 years ago: "Minireview: Lactose Intolerance," J. Kocian, International Journal of Biochemistry, 1988;20(1):1-5, p. 1.

box -- High Lactose=Few Symptoms?

3. recent study: "Correlation of lactose maldigestion, lactose intolerance, and milk intolerance," Abiodun O. Johnson et al., American Journal of Clinical Nutrition, 1993;57:399-401.

4. relation of lactose & symptoms: "Clinical Picture of Hypolactasia and Lactose Intolerance," K. Villako & H. Maaroos, Scandinavian Journal of Gastroenterology, 1994;29(suppl 202):36-54, p. 43; conversation w/ Dr. Dennis Savaiano, 9/29/94 on unpublished research.

6. "unbearable" Dr. William Chey, quoted in "A 'benign' but 'unbearable' disease," Susan J. Smith, Rochester Democrat & Chronicle, 4/30/86.

7. 1959: "Defective Lactose Absorption Causing Malnutrition in Infancy," A. Holzel, V. Schwarz & K. W. Sutcliffe, Lancet, May 30, 1959, pp. 1126-8.

7. 40 cases: "Small-Intestinal Disaccharidases," Giorgio Semenza & Salvatore Auricchio, p. 2988. Ch. 121 in Metabolic Basis of Inherited Disease, Volume II, 6th Edition, Charles R. Scriver, Arthur L. S. Sly, William Beaudet & David Valle, eds. NY: McGraw-Hill, 1987.

8. no way to restart lactase: "Lactose Intolerance and Yogurt, Part 2 -- Diagnosis and Treatment" Michael D. Levitt & Dennis A. Savaiano, Practical Gastroenterology, 1985;9(2):41-4, p. 43.

9. $200,000,000: enzymes, $34.8M; milk products, "more than twice"; soymilks, "approaching $100M"; "Cow-ering from Dairy Products: Lactose Intolerance Marketing," Judith Schwartz, Brandweek, 5/2/94, pp. 50, 52; enzymes, $40M, "Does Milk Shake You Up?" Diane Debrovner, American Druggist, 9/93, p. 44; industry, $117M in 1992, "Milking a Fad," Christine Gorman, Time, 5/17/93, p. 53; plus nondairy creamer sales.

9. 1 in 4: Dairy Ease promotional literature

9. 25%: Interview with Tom Mekus of Vitamite

9. 80,000,000: Consumers' Research, 6/93

9. Levitt quote: Consumers' Research, ibid.

9. McGill quote: Gorman, ibid.

box -- LI: Running the Numbers

Statistical Abstract: 1994 edition, table ???

Chapter 2 -- The Scandalous History of Lactose Intolerance

13. Kretchmer quote: "Lactose and Lactase," Norman Kretchmer, Scientific American, Oct, 1972.

14. Hippocrates & Galen quotes: "Genetics and Epidemiology of Adult-type Hypolactasia," T. Sahi, Scandinavian Journal of Gastroenterology, 1994;29(suppl 202):7-20, p. 17.

14. Burton quote: Hunger and History, E. Parmalee Prentice. NY: Harper & Brothers, 1939, p. 155.

14. French physician quote: Prentice, ibid, p. 158.

14. Hoffmann quote: Prentice, ibid, p. 165.

15. milk train: Prentice, ibid, pp. 181-2.

15. dirty cheese: Food in History, 2nd ed., Reay Tannahill. NY: Crown, 1989, p. 308.

15. early chronology: "Hypolactasia and Lactase Persistence: Historical Review and the Terminology," T. Sahi, Scandinavian Journal of Gastroenterology, 1994;29(suppl 202):1-6, p. 1.

15. Jacobi quote: "Milk-Sugar in Infant Feeding," Abraham Jacobi, Transactions of the American Pediatric Society, 1901;13:150-60, p. 151.

15. Howland quote: "Prolonged Intolerance to Carbohydrates," John Howland, Transactions of the American Pediatric Society, 1921;33:11-19, p. 11.

16. 1959 report: "Defective Lactose Absorption Causing Malnutrition in Infancy," A. Holzel et al., Lancet, May 30, 1959, pp. 1126-8.

16. 1966 study: "A Racial Difference in Incidence of Lactase Deficiency," Theodore M. Bayless & Norton S. Rosensweig, Journal of the American Medical Association, 1966;197:968-72 (Sept. 19, 1966).

16. study, two years later: "Milk and Lactose Intolerance in Healthy Orientals," Sui-Shung Huang & Theodore M. Bayless, Science, 1968;160:83-4 (April 5, 1968).

16. footnote, gap in former USSR: "Genetics of Lactose Digestion in Humans," Gebhard Flatz, p. 49. Ch. 1 in Advances in Human Genetics, Harry Harris and Kurt Hirschhorn, eds. NY: Plenum Press, 1987; Sahi, "Genetics," ibid, p. 13.

16. Appendix I: "The Acceptability of Milk and Milk Products in Populations with a High Prevalence of Lactose Intolerance," Nevin S. Scrimshaw and Edwina B. Murray, American Journal of Clinical Nutrition, 1988;48:1080-1159.

16. one in 100,000,000: extrapolated off the number of congenital LI cases worldwide; number would be 100,000 if other ailments, such as galactosemia, were included.

16. first year of life: "Clinical Picture of Hypolactasia and Lactose Intolerance," K. Villako & H. Maaroos, Scandinavian Journal of Gastroenterology, 1994;29(suppl 202):36-54, p. 39.

17. white vs. nonwhite: The Sacred Cow and the Abominable Pig: Riddles of Food and Culture (originally published as Good to Eat), Marvin Harris. NY: Touchstone/Simon & Schuster, 1985. pp. 136-7.

18. dairying and nondairying: "Lactose Malabsorption: Its Biology and History," John D. Johnson, Norman Kretchmer & Frederick J. Simoons, Advances in Pediatrics, 1974;21:197-237, pp. 215-7.

18. psychosomatic: Johnson, Kretchmer & Simoons, ibid, p. 217.

19. footnote 3: "An Interdisciplinary Look at Lactose Malabsorption," Daniel S. May, The American Biology Teacher, 1985;47(3):154-8, p. 155; Flatz, "Genetics," pp. 12-3; Sahi, "Hypolactasia," ibid, p. 3.

19. plant diversity: "Paleolithic Nutrition: A Consideration of Its Nature and Current Implications," S. Boyd Eaton & Melvin Konner, The New England Journal of Medicine, 1985;312(5):283-9 (Jan. 31, 1985).

19. somewhere around that time: "Did Persistence of Intestinal Lactase Into Adult Life Originate on the Arabian Peninsula?" G. C. Cook, Man (N.S.), 1978;13:418-27; p. 424; Eaton & Konner, ibid; Johnson, Kretchmer & Simoons, ibid, p. 214.

box -- Genetic Mutation and Natural Selection

21. food historian quote: Tannahill, ibid, pp. 124-5

21. alleles & blood types: "Putting Human Genes on the Map," Christopher Wills, Natural History, 6/94, p. 82-3


21. three conditions: Johnson, Kretchmer & Simoons, ibid, p. 220.

22. Beja: Flatz, ibid, p. 51-2.

22. other tribes: Flatz, ibid, p. 52.

22. culture historical hypothesis: "Lactase Deficiency: An Example of Dietary Evolution," Robert D. McCracken, Current Anthropology 1971;12(4-5):479-517; "The Geographic Hypothesis and Lactose Malabsorption: A Weighing of the Evidence," Frederick J. Simoons, Digestive Diseases, 1978;23(11):963-80; Sahi, "Genetics," ibid, pp. 10-11; Flatz, ibid, pp. 49-52.

23. Colin Renfrew: "The Origins of Indo-European Languages," Scientific American, Oct. 1989, pp. 106-14; Archaeology and Language: The Puzzle of Indo-European Origins, Cambridge Univ. Press, 1988.

24. earliest evidence of rickets: Food in Antiquity: A Survey of the Diet of Early Peoples, Don and Patricia Brothwell. NY: Frederick A. Praeger, 1969. p. 181.

24. improves calcium absorption: "Effects of Lactose on Intestinal Calcium Absorption in Normal and Lactase-Deficient Subjects," Bernard Cochet et al., Gastroenterology, 1983;84:935-40.

25. evidence is mixed: "The clinical significance of disaccharide maldigestion," Eivind Gudmond-Hoyer, American Journal of Clinical Nutrition, 1994;59(suppl):735-41S.

25. majority of reports: Villako & Maaroos, ibid, p. 43.

25. calcium absorption hypothesis: Flatz, "Genetics," ibid; Johnson, Kretchmer & Simoons, ibid, Harris, ibid.

box -- Eat Your Liver if You Don't Drink Your Milk

26. Eskimos: Harris, ibid, p. 139.

26. Pinnipedia: Harris, ibid, p. 143.

26. Arabian desert: Cook, ibid, p. 425.

26. butter: Much Depends on Dinner, Margaret Visser. NY: Grove Press, 1986, ch. 3 passim.

27. peat bog butter: Prentice, ibid, p. 156

box -- A Quick Look at Milkless Cultures

27. general discussion: Harris, ibid, ch. 3, 7 passim.

27. India and milk: Classic Indian Cooking, Julie Sahni. NY: William Morrow & Co., 1980, pp. 47+

28. minority view: Cook, ibid.

29. coevolution: "Time Required for Gene Frequency Change in a Deterministic Model of Gene-Culture Coevolution with Special Reference to the Lactose Absorption Problem," K. Aoki, Theoretical Population Biology, 1991;40:354-68

29. reversed-cause argument: Aoki, ibid, p. 366, quoting McCracken.


Chapter 3 -- Starting with a Sweet Tooth: Lactose and Milk

31. from the Latin: The World of Carbon, (rev. ed.), Isaac Asimov. NY: Collier Books, 1962, p. 103.

31. from the Greek: Asimov, ibid.

31. Bartoletti & Scheele: "Lactose and Lactitol" by P. Linko in Nutritive Sweeteners, G. G. Birch & K. J. Parker, eds. London: Applied Science Publishers, 1982, p. 110.

31. glucose, basic energy source: Asimov, ibid, p. 101.

box -- Glucose in the Bloodstream

31. one-fifth of an ounce: Asimov, ibid, p. 101.

31. 22.7 Calories: Food Science, 4th Ed., Norman N. Potter. Westport, CT: AVI Publishing, 1986, p. 60. Calculation: 1/5 oz = 5.675 g. Sugars are 98% fully digested and provide 4 kcal/g. 5.675 x 4 = 22.7 kcal = 22,700 cal = heat to raise 22,700 g H2O 1C. 22,700 g = 50 lb.

31. 15 minutes: Asimov, ibid, p. 101.

31. glycogen: Nutrition in Clinical Care, Roseanne Beatrice Howard and Nancie Harvey Herbold. NY: McGraw-Hill, 1978, p. 55.

31. Glucose, found in nature: World Book Encyclopedia, 1978, Vol. 8, "Glucose," p. 226.


Table 1 -- Simple and Compound Sugars

32. relative sweetness: Ingredients for Bakers, Samuel A. Matz. McAllen, TX: Pan-Tech International, 1987, p. 117.

32. notes: Matz, chapter 5, passim.

33. lactose, full formal name: Linko, ibid, p. 111.

33. condensation, hydrolysis: Asimov, ibid, pp 103, 106

33. sugar sweetnesses: Asimov, ibid, pp 104.

34. lactose helps in dozen ways: Linko, ibid, pp. 117-20.

Table 2: Milk from Many Mammals

35. adapted from Milk and Milk Products in Human Nutrition, 2nd ed, rev., FAO Nutritional Studies, No. 27, S. K. Kon. Rome: Food and Agricultural Organization of the United Nations, p. 3.

35. mare's milk -- Food in History, Reay Tannahill. NY: Stein & Day, 1973, pp. 131-2.

36. double their birth weight: Kon, ibid, p. 2.

36. sea lion milk: "Lactose and Lactase," Norman Kretchmer, Scientific American, Oct, 1972.

36. monotremes: Mammals, Guiseppe Minelli. NY: Facts on File, 1987, p. 22.

36. pinnipedia: Kretchmer, ibid.

36. nutritional usefulness: Newer Knowledge of Milk and Other Fluid Dairy Products, National Dairy Council, 1993, p. 20.

36. human vs. cow's milk: Newer Knowledge of Milk, p. 33.

Table 3 -- Percentage of Total U.S. Intake of Nutrients That Is Supplied by Dairy Foods (Excluding Butter), 1988

37. adapted from Newer Knowledge of Milk, p. 34.

Chapter 4 -- Nutrients: Good Health With or Without Lactose

39. milk contains: Newer Knowledge of Milk and Other Fluid Dairy Products, National Dairy Council, 1993, passim.

39. magnesium deficiency study: cited in Recommended Dietary Allowances, 10th ed., Food and Nutrition Board, National Research Council, Washington, DC: National Academy Press, 1989, p. 189.

40. RDAs: ibid.

40. RDA flaws: The Essential Guide to Vitamins & Minerals, Elizabeth Somer: Health Media of America, NY: HarperPaperbacks, 1992, pp. 10-11.

41-4. carbohydrates, general: Jane Brody's Nutrition Book, NY; Bantam, 1987, pp. 144-54; The Tufts University Guide to Total Nutrition, Stanley Gershoff with Catherine Whitney. NY: HarperPerennial, 1990, pp. 15-17.

41. Dave Barry quote: Stay Fit & Healthy Until You're Dead, Emmaus, PA: Rodale Press, 1985, p. 46.

Table 1 -- Recommended Dietary Allowances, revised 1989

42-3. adapted from RDAs, ibid, p. 285.

Table 2 -- Food Value in a Glass of Milk

44. adapted from Newer Knowledge of Milk , p. 38.

45-6. proteins, general: Brody, ibid, pp. 35-6, 45-7; Gershoff, ibid, p. 9.

46. infants and children: RDAs, ibid, p. 63.

46. athletes: Nutrition in Clinical Care, Roseanne Beatrice Howard and Nancie Harvey Herbold. NY: McGraw-Hill, 1978, p. 47.

46. complements: "Vegetarian Diets: The Pluses and the Pitfalls," Dixie Farley, FDA Consumer, 5/92, pp. 21-4.

46. body digests: RDAs, ibid, p. 69.

46-9 fats and lipids, general: Brody, ibid, pp. 55-6, 62; Gershoff, ibid, pp. 19-23.

47. triglycerides and sat fats: -- Food Science, 4th Ed., Norman N. Potter. Westport, CT: AVI Publishing, 1986, p. 83.

48. NRC recommendations: RDAs, ibid, pp. 49-50.

49-51. vitamins, general (including Table 3 -- Nondairy Sources of Vitamins): Somer, passim; Potter, ibid, pp. 71-5; Brody ibid, pp. 154-67.

49. 15000 year supply: RDA=5 mcg. 1 oz = 28,375,000 mcg = 5,675,000 daily doses. divided by 365 = 15547 years.

51. denying all sun counterproductive: Calcium and Common Sense, Robert P. Heaney & M. Janet Barger-Lux. NY: Doubleday, 1988, pp. 48-9.

51-2. minerals, general: Somer, passim.

Table 4 -- Nondairy Sources of Minerals

52. Brody, ibid, pp. 184, 187.

52. vast majority of Americans: "Calcium: Are You Getting Enough?" Julia Malloy, Better Homes & Gardens, 4/92, p. 40.

53. uses of blood calcium: Food Values: Calcium, Leah Wallach. NY: Harper & Row, 1989, p. xiii.

53. bone remodeling: Wallach, ibid, pp. xii-xiii.

53. Type I, II osteoporosis: "Osteoporosis Treatment Advances," Ruth Papazian, FDA Consumer, 4/91, p. 29.

54. bullets: 1&3) Wallach, ibid, p. xi; 2) "The truth about calcium," Consumer Reports, 5/88, p. 288.

54. past age 35: "Comparative Uptake of Calcium From Milk and a Calcium-Rich Mineral Water in Lactose Intolerant Adults: Implications for Treatment of Osteoporosis," Georges M. Halpern et al., American Journal of Preventive Medicine, 1991;7(6):379-83, p. 380.

54. study of adolescent girls: The Journal of the American Medical Association, 8/18/93, quoted in "A Case for Calcium," Vegetarian Times, 11/93, p. 16.

54. bodily fluids: Heaney & Barger-Lux, ibid, p. 11.

54. bad health habits: The Calcium Bible, Patricia Hausman, NY: Rawson Assoc., 1985, pp. 41-2; Heaney & Barger-Lux, ibid, pp. 78-80.

Table 5 -- Nondairy Dietary Sources of Calcium

55. Food Values of Portions Commonly Used, 14th ed., Jean A. T. Pennington & Helen Nichols Church. NY: Harper & Row, 1985, p. 232; Hausman, ibid, p. 64.

55. 75%: Newer Knowledge of Milk, ibid, p. 34.

56. incorporate bone into diet: Heaney & Barger-Lux, ibid, p. 56.

57. high bioavailability: Heaney & Barger-Lux, ibid, p. 59.

57. hard water: Heaney & Barger-Lux, ibid, p. 52.

57. tofu & tortillas: "Need calcium? Try tofu and tortillas . . .," Science News, 3/12/88, p. 174.

57. alligator meat: Osteoporosis--The Silent Thief, William A. Peck & Louis V. Avioli. Washington, D.C.: AARP/Glenview, IL: Scott, Foresman, 1988, p. 67.

57. citrate better absorbed: Heaney & Barger-Lux, ibid, p. 173; Preventing Osteoporosis, Kenneth H. Cooper. NY: Bantam, 1989, p. 219.

58. better than phosphate: Peck & Avioli, ibid, p. 83; Heaney & Barger-Lux, ibid, p. 173.

Table 6 -- Percentages of Elemental Calcium

58. Hausman, ibid, p. 97; Peck & Avioli, ibid, p. 84; Heaney & Barger-Lux, ibid, p. 168; USP DI-Volume II -- Advice for the Patient: Drug Information in Lay Language, Edition 14, 1994.

58. variations among individuals: "A study of five calcium supplements: Estimation of calcium absorption and sodium content," R. N. Johnson, European Journal of Clinical Nutrition, 1991;45:117-9, p. 117.

58. bioavailability: "Osteoporosis: Prevention and Management," American Pharmacy, Judith M. Riffee, 1992;NS32(8):61-71, p. 68.

58. Ca carbonate w/ a meal: "Calcium Supplements: Getting the Goods," Harvard Medical School Health Letter, 10/85

58. dissolvability: Consumer Reports, 5/88, p. 291.

59. now not a problem: "Calcium: After the Craze," Bonnie Liebman, Nutrition Action Healthletter, 6/94, p. 8.

59. vitamin D: Hausman, ibid, p. 33; Wallach, ibid, p. xix.

59. FDA warning: "Potential Toxicity Due to Dolomite and Bonemeal," H. J. Roberts, Southern Medical Journal, 1983;76(5):556-9.

59. Consumer Reports: "How safe are calcium supplements?" 10/93, p. 625.

59. AJPH: "Lead Content in 70 Brands of Dietary Calcium Supplements," Bernard P. Bourgoin et al., American Journal of Public Health, 1993;83(8):1155-60.

61. FDA study: cited in Bourgoin, ibid, p. 1159.

61-2. general advice: Peck & Avioli, ibid, pp. 79, 80, 83, 84; Hausman, ibid, pp. 91-102; Heaney & Barger-Lux, ibid, pp. 166-179; Liebman, ibid, pp. 8-9; USP Advice for the Patient.

61. bedtime: "Nutritional Factors in Causation of Osteoporosis," R. P. Heaney, Annales Chirurgiae et Gynaecologiae, 198;77:176-9.

62. total calcium intake: Somer, ibid, p. 320.

62. kidney stones: Somer, ibid, p. 320; Gershoff, ibid, p. 39.

63. Li Wan Po quote: "Calcium Supplements and Postmenopausal Osteoporosis," The Pharmaceutical Journal, 7/28/90, p. 119.

63. Heaney quote: Heaney, "Nutritional Factors," p. 177.

63. exercise: Osteoporosis: Brittle Bones and Calcium Crisis, Kathleen Mayes. Santa Barbara, CA: Pennant Books, 1986, pp. 108-9; Peck & Avioli, ibid, p. 38.

63. estrogen: Heaney & Barger-Lux, ibid, pp. 200-1.

64. ERT controversy: Riffee, ibid, pp. 64-5.

Chapter 5 -- Lactose Digestion: The Inside Story

66. Wine-making: Discovering Enzymes, David Dressler and Huntington Potter. NY: HPHLP/Scientific American Library, 1991, p. 23.

66-7. Pasteur quote: Dressler & Potter, ibid, p. 35.

67. Greek words: The Chemicals of Life, Isaac Asimov. NY: Signet, 1954, p. 32.

67. Fischer: Dressler & Potter, ibid, p. 65.

67. catalysts: Asimov, ibid, chapters 2, 3 passim.

68. lock and key: Dressler & Potter, ibid, p. 65.

footnote 1: Biology, Peter H. Raven & George B. Johnson. St. Louis: Times Mirror/Mosby College Publishing, 1986, p. 59.

General discussion of digestion throughout: Gut Reactions: UnderstandingSymptoms of the Digestive Tract, W. Grant Thompson. NY: Plenum Press, 1989, Gut, pp. 3-27.

70. boxing glove: The Digestive System, Regina Avraham. NY: Chelsea House, 1989, p. 47.

71. 50 times: Raven & Johnson, ibid, p. 930.

71. Vomiting: The Human Body: Its Structure and Operation, Isaac Asimov. NY: Signet, 1963, p. 219.

71. hydrochloric acid: Avraham, ibid, p. 48.

71. 3 million times: Raven & Johnson, ibid, p. 927.

72. mucin: The Digestive System, 2nd ed., R. J. Ryall. Edinburgh: Churchill Livingstone, 1984, p. 62.

72. heartburn and hiatus hernia: Ryall, ibid, pp. 37, 43-4.

73. 3,000 square feet: (actually 3227) Raven & Johnson, ibid, p. 931.

73. 5,000 sq ft: (actually 5400) Avraham, ibid, p. 53.

73. 9,000 sq ft: (actually 8611) Tabor's Cyclopedic Medical Dictionary, Edition 15, Philadelphia: F. A. Davis Co., 1985, p. 864.

73. jejunum/ileum 40/60 ratio: Tabor's, ibid, p. 864; Asimov, Human Body, p. 227.

73. jejunum actually longer: Thompson, ibid, p. 12.

74. alkalinity of bile salts & pancreatic juice: Asimov, Human Body, p. 222.

74. liver has 500 jobs: Avraham, ibid, p. 50.

74. bile also known as gall: Asimov, Human Body, p. 224.

74. five hours: Avraham, ibid, p. 53.

74. rolled up carpet sample: Raven & Johnson, ibid, p. 932.

74. vitamins and minerals: Avraham, ibid, p. 53.

75. microvilli: "Carbohydrate Digestion: Effects of Monosaccharide Inhibition and Enzyme Degredation of Lactase Activity," D. H. Alpers, Ch. 5 in Lactose Digestion: Clinical and Nutritional Implications, David M. Paige & Theodore M. Bayless, eds. Baltimore: Johns Hopkins University Press, 1981; "Lactose and Lactase," Norman Kretchmer, Scientific American, Oct, 1972.

75. packed together so tightly: "Genetic Polymorphism of Intestinal Lactase Activity in Adult Humans", Gebhard Flatz, Ch. 122 in Metabolic Basis of Inherited Disease,Volume II, 6th Edition, Charles R. Scriver, Arthur L. S. Sly, William Beaudet & David Valle, eds. NY: McGraw-Hill, 1987, p. 2977.

75. at best never more than: Alpers, ibid, p. 58.

75. volume of liquids: Raven & Johnson, ibid, p. 932.

76. cecum: Asimov, Human Body, p. 235.

76. the other half: Avraham, ibid, p. 55.

76. vitamin K: Raven & Johnson, ibid, p. 935.

76. newborn babies: "Carbohydrate Intolerance and the Enteric Microflora," Jay A. Perman, Ch. 10 in Carbohydrate Intolerance in Infancy, Fima Lifshitz, ed. NY: Marcel Dekker, 1982, p. 137.

78. sucrose vs. lactose: Alpers, ibid, p. 58.

78. increase fivefold: "Genetics of Lactose Digestion in Humans," Gebhard Flatz, ch 1 in Advances in Human Genetics, Harry Harris and Kurt Hirschhorn, eds. NY: Plenum Press, 1987, p. 15.

78. footnote 2: "Intestinal Osmotic and Kinetic Effects of Carbohydrate Malabsorption," Raul A. Wapnir, Ch. 9 in Carbohydrate Intolerance in Infancy, Fima Lifshitz, ed. NY: Marcel Dekker, 1982, pp. 122-5; "Lactose Intolerance and Yogurt: Part 1 -- Understanding the Problem," Michael D. Levitt & Dennis A. Savaiano, Practical Gastroenterology, 1985;9(1):12-29, pp. 13, 29.

79. to the colon: Flatz, ibid, p. 15.

79. result: "Clinical Aspects of Lactose Intolerance in Children and Adults," H. A. Buller et al., Scandinavian Journal of Gastroenterology, 1991;26(suppl 188):73-80, p. 75.

79. quickly and severely: Buller, ibid, p. 75.

79. as soon as possible: Dr. Robert Kornfield, interview, 3/1/94


Chapter 6 -- The Wonderful World of Dairy Products --

81+. general milk description: Newer Knowledge of Milk and Other Fluid Dairy Products, National Dairy Council, 1993, passim; Code of Federal Regulations, Title 21, parts 100-169, revised as of April 1, 1994.

box -- Don't Drink Your Milk?

82. PCRM, Oski quotes: "Cow's Milk and Children: A New No-No?" Marian Burros, New York Times, 9/30/92, pp. C1,6.

82. vitamin D: "Decidedly D-ficient," Mark Harris, Vegetarian Times, 3/94, p. 17; "Don't Drink Your Milk!" Nathaniel Mead, Natural Health, 7-8/94, p. 71.

82. BST: Harris, ibid.

82. linking milk: "Dairy Tales, Kimberly Knight, Essence, 5/93, p. 30; Mead, ibid.

82. PRCM also advocates: "Doctor Spock Adds Clout to Warnings About Cow's Milk," David Stipp, Wall Street Journal, 9/30/92.

82. Liebman quote: Burros, ibid.

82. Eisenbarth quote: "Doctors warn of milk hazards," Judy Foreman, Boston Globe, 9/30/92, p. 3.

82. King quote: Burros, ibid.

83. establishment groups: Knight, ibid.

83. Oski pro-milk quote: Burros, ibid.

83. Spock position: Burros, ibid.

83. AAP position: Stipp, ibid.

83. the FDA allows: CFR 21, part 101.4, "Food, designation of ingredients," p. 19.

85. 3.6%: Ingredients for Bakers, Samuel A. Matz. McAllen, TX: Pan-Tech International, 1987, p. 168.

86. Traditionally, names referred: Food in History, Reay Tannahill. NY: Stein & Day, 1973, p. 134.

87. Acidophilus milk: "Lactose Intolerance and Its Modulation with Lactobacilli and Other Microbial Supplements," Custy F. Fernandes & Khem M. Shahani, Journal of Applied Nutrition, 1989;41(2):50-64; "Modification of sweet acidophilus milk to improve utilization by lactose-intolerant persons," Frank E. McDonough et al., American Journal of Clinical Nutrition, 1987;45:570-4.

87. One study: "Effect of fermentation on lactose, glucose, and galactose content in milk and suitability of fermented milk products for lactose intolerant individuals," L. Alm, Journal of Dairy Science, 1982;65:346-52, quoted in Fernandes & Shahani, p. 55.

90. name phased out: "Say Good-Bye to Ice Milk," Donna Gorski, Dairy Foods, 4/94, p. 34.

90+. cheese, general discussion: Milk and Milk Products in Human Nutrition, 2nd ed, rev., FAO Nutritional Studies, No. 27, S. K. Kon. Rome: Food and Agricultural Organization of the United Nations, pp. 51-8.

91. Italian name of ricotta: The Ideal Cheese Book, Edward Edelman and Susan Grodnick. NY: Harper & Row, 1986, p. 7.

91. whey cheeses: The World Guide to Cheese, Sonya Mills. NY: Gallery Books, 1988, pp. 43-4.

96. One study: "Do Lipids Play a Role in Milk Intolerance?" J. P. Costet, et al., pp. 156-61 in Milk Intolerances and Rejections, J. Delmont, ed. Basel: Karger, 1983.

Table 1 -- Percentages of Lactose in Dairy Products

97+. ranges: "The Acceptability of Milk and Milk Products in Populations with a High Prevalence of Lactose Intolerance," Nevin S. Scrimshaw and Edwina B. Murray, American Journal of Clinical Nutrition, 1988;48:1080-1159.

97+. averages: Newer Knowledge of Milk, passim.

98. whey ranges: Ingredient Description Brochure, American Dairy Products Institute, 1992, passim.

98+. additional cheese ranges: Matz, ibid, p. 184.

Chapter 7 -- --And How to Eat Them

100. chart: adapted from "Small-Intestinal Disaccharidases," Giorgio Semenza & Salvatore Auricchio, Ch. 121 in Metabolic Basis of Inherited Disease Volume II, 6th Edition, Charles R. Scriver, Arthur L. S. Sly, William Beaudet & David Valle, eds. NY: McGraw-Hill, 1987, p. 2987.

100. impossible to predict: "Correlation of lactose maldigestion, lactose intolerance, and milk intolerance," Abiodun O. Johnson et al., American Journal of Clinical Nutrition, 1993;57:399-401.

101. 80%: "Recent Advances in the Management of LI," Dennis A. Savaiano & Catherine Kotz, Contemporary Nutrition, 1988;13(9,10):1-4.

101. one such study: "Cocoa feeding and human lactose intolerance," Chong M. Lee & Christine M. Hardy, American Journal of Clinical Nutrition, 1989;49:840-4.

105. an elegant experiment: "Reduced intolerance symptoms from lactose consumed during a meal," Margaret C. Martini & Dennis A. Savaiano, American Journal of Clinical Nutrition, 1988;48:57-60.

105. anything that delays rate: "Lactose intolerance: Pinpointing the source of nonspecific gastrointestinal symptoms," Ramon G. Montes & Jay. A. Perman, Postgraduate Medicine, 1991;89(8):175-84, p. 183.

105. solids and semi-solids: "All yogurts are not created equal," Dale H. Wytock & Jack A. DiPalma, American Journal of Clinical Nutrition, 1993;47:454-7, p. 456.

105. chocolate milk: Lee & Hardy, ibid

106. high-fiber diet: Jane Brody's Nutrition Book, Jane Brody. NY; Bantam, 1987, pp. 144-54; The Tufts University Guide to Total Nutrition, Stanley Gershoff with Catherine Whitney. NY: HarperPerennial, 1990, p. 147.

106. Abraham: "Lactose Intolerance and Yogurt: Part 2 -- Diagnosis and Treatment," Michael D. Levitt & Dennis A. Savaiano, Practical Gastroenterology, 1985;9(2):41-4, p. 43.

106. dahi, taetta: Food in History, Reay Tannahill. NY: Stein & Day, 1973, p. 132.

106. 8th century Turkish records: Levitt & Savaiano, ibid.

106. Assyrians: "Yogurt: The Curds and Whey to Health?" Rebecca D. Williams, FDA Consumer, 6/92, p. 29.

106. Dannon Corporation: The Book of Yogurt, Sonia Uvezian. San Francisco: 101 Productions, 1978, p. 12.

106. American yogurt market: Wellness Encyclopedia of Food and Nutrition, Sheldon Margen & the Editors of the University of California at Berkeley Wellness Letter. NY: Rebus, 1992, p. 478.

107. similar manufacturing process: "Yogurt -- An Autodigesting Source of Lactose," Joseph C. Kolars et al., The New England Journal of Medicine, 1984;310(1);1-3, p. 2; Levitt & Savaiano, ibid; Williams, ibid.

107. additional 30%: Kolars, ibid, p. 3; Levitt & Savaiano, ibid, p. 43.

107. thicken the yogurt: Margen, ibid, p. 478.

107. L. Acidophilus: Newer Knowledge of Milk, p. 12.

107. footnote 3: lower in lactose: "Lactose Malabsorption: Its Biology and History," John D. Johnson, Norman Kretchmer & Frederick J. Simoons, Advances in Pediatrics, 1974;21:197-237, p. 221.

108. 50-100%: Kolars, ibid, p. 2.

108. one-third: Kolars, ibid, p. 3.

108. can't count on yogurt: "Lactose digestion from yogurt: influence of a meal and additional lactose," Margaret C. Martini, Denise Kukielka and Dennis A. Savaiano, American Journal of Clinical Nutrition, 1991;53:1253-8, p. 1257.

108. reduced gastric emptying: Martini, ibid.

108. before freezing: "Lactose digestion from flavored and frozen yogurts, ice milk, and ice cream by lactase-deficient persons," Margaret C. Martini, David E. Smith and Dennis A. Savaiano, American Journal of Clinical Nutrition, 1987;46:636-40, p. 639.

109. Dairy Foods study: "Benefitting from a Healthy Image," Claudia Dziuk O'Donnell, 4/93, pp. 93-100.

109. Dr. Savaiano confirmed: phone interview, 9/28/94.

109. homemade yogurt: Margen, ibid, p. 482.

box -- The National Yogurt Association's Live Culture Seal

109. NYA Live and Active Culture Yogurt Seal Program Procedure, revised Sept. 1993.


box -- Homemade Yogurt

110. Adapted from Uvezian, ibid.

109. global feeding programs: "The Acceptability of Milk and Milk Products in Populations with a High Prevalence of Lactose Intolerance," Nevin S. Scrimshaw and Edwina B. Murray, American Journal of Clinical Nutrition, 1988;48:1080-1159, p. 1118.

111. nothing will bring back: "Hypolactasia and Lactase Persistence: Historical Review and the Terminology," T. Sahi, Scandinavian Journal of Gastroenterology, 1994;29(suppl 202):1-6, p. 3; "Genetics of Lactose Digestion in Humans," Gebhard Flatz, Ch. 1 in Advances in Human Genetics, Harry Harris and Kurt Hirschhorn, eds. NY: Plenum Press, 1987, p. 13.

111. 21 species: "Metabolism of Lactose in the Human Body," H. Arola & A. Tamm, Scandinavian Journal of Gastroenterology, 1994;29(suppl 202):21-5, p. 22.

111. sudden availability: "Bacterial Adaptation to Lactase Deficiency," M. J. Hill, pp. 22-5 in Milk Intolerances and Rejections, J. Delmont, ed. Basel: Karger, 1983.

111. highly acid colon: Arola & Tamm, ibid, p. 23.

111. without formic acid: Hill, ibid, p. 24.

111. Regular doses: Hill, ibid, p. 25.

111. footnote 34 Bacteroides: Arola & Tamm, ibid, p. 23.

112. Gilat study: quoted in "Management of Lactose Intolerance," A. Tamm, Scandinavian Journal of Gastroenterology, 1994;29(suppl 202):55-63, p. 59.

112. Tamm quote: Tamm, ibid, p. 60.

112. A separate review: "The clinical significance of disaccharide maldigestion," Eivind Gudmand-Hoyer, American Journal of Clinical Nutrition, 1994;59(suppl):735S-741S, p. 736S.

112. study with American volunteers: "Adaptation of lactose maldigesters to continued milk intakes," Abiodun O. Johnson et al., American Journal of Clinical Nutrition, 1993;58:879-81.

Chapter 8 -- The Lactase Phase

115. Gist-Brocades: "Commercialization of Lactases and Lactose-Hydrolyzed Milk in USA," Alan Klingerman, pp. 66-71 in Milk Intolerances and Rejections, J. Delmont, ed. Basel: Karger, 1983.

115. lactose molecular weight 342: Maxilact technical data sheet Mil-13/80-03.En.03

115. lactase molecular weight 280,000: "Lactose Intolerance," Emanuel Lebenthal, pp. 367-88 in Digestive Diseases in Children, Emanuel Lebenthal, ed. NY: Grune & Stratton, 1978, p. 368; "Intestinal Disaccharidases: structure, function, and deficiency," Robert K. Montgomery, Maureen M. Jonas and Richard J. Grand, Ch. 6 in Carbohydrate Intolerance in Infancy, Fima Lifshitz, ed. NY/Basel: Marcel Dekker, 1982, p. 79.

115. used in Russia: Gist-brocades Maxilact Technical Bulletin.

115. Maxilact history: Klingerman, ibid, p. 69.

116. various lactases: "Management of Lactose Intolerance," A. Tamm, Scandinavian Journal of Gastroenterology, 1994;29(suppl 202):55-63; "Enzyme Replacement for Lactose Malabsorption Using a Beta-D- Galactosidase," Jack A. DiPalma & Mark S. Collins, Journal of Clinical Gastroenterology, 1989;11(3):290-3.

116. food supplement: Interview, Dr. Michael Kaplan, McNeil Consumer, 10/20/94.

117. FCC units: Food Chemicals Codex III, General Tests and Apparatus, p. 492.

117. proprietary studies: Gist-brocades information sheet, undated.

117. clinical studies: "All Lactase Preparations Are Not the Same: Results of a Prospective, Randomized, Placebo-Controlled Trial," Francisco C. Ramirez, Kelvin Lee and David Y. Graham, The American Journal of Gastroenterology, 1994;89(4)566-70.

117. a review: Tamm, ibid.

117. Enter Alan Klingerman: "N.J. man takes misery out of milk," Joyce A. Venezia, Daily Record, Morris County, NJ, 2/26/89, p. A10.

118. Dairy Ease: Dairy Ease promotional literature.

118. advertising blitz: "Cow-ering from Dairy Products: LI Marketing," Judith Schwartz, Brandweek, 5/2/94, p. 52.

118. 1989 sales: Dairy Ease sales brochure.

118. 1993 sales: Schwartz, ibid, pp. 50, 52.

118. double-digit increases: "Lactose Intolerance an Opportunity, Not a Threat," Jerry Dryer, Dairy Foods, 12/94, p. 14.

118. pill sales stagnant: Schwartz, ibid, p. 50.

118. Lactaid's hotline: "Does Milk Shake You Up?" Diane Debrovner, American Druggist, 9/93, p. 44.

118. 9 of 10: Rameriz, ibid, p. 567.

119. market shares: Schwartz, ibid, p. 50.

119. Lactrase: "LI products overflowing onto OTC shelves," Kathi Gannon, Drug Topics, 2/3/92, p. 39.

119. Brandweek quote: Schwartz, ibid, p. 54.

119. sales of pills: Schwartz, ibid, p. 50.

120. Dairy Ease chose: Schwartz, ibid, p. 52.

121. pill advice and quote: Interview, Dr. Pol Vandenbroucke, Sterling Winthrop, 10/20/94.

121. effectiveness studies: Kaplan interview, 10/20/94.

121. poor stability: Kaplan interview, 10/20/94.

123. Lin experiment: "Comparative Effects of Exogenous Lactase (ß-Galactosidase) Preparations on in Vivo Lactose Digestion," M.-Y. Lin et al., Digestive Disease and Sciences, 1993;38(11):2022-27.

123. Ramirez experiment: Ramirez, Lee and Graham, ibid.

124. footnote 3: "Does Oral Enzyme Replacement Therapy Reverse Intestinal Lactose Malabsorption?" Morry Moskowitz, Craig Curtis and Judith Gavaler, The American Journal of Gastroenterology, 1987;82(7):632-5: DiPalma & Collins, ibid.

125. some studies: "Enzyme Replacement Therapy for Primary Adult Lactase Deficiency," Jorge L. Rosado et al., Gastroenterology, 1984;87:1072-82; A. Tamm, ibid.

125. UHT processing: letter from Christopher J. Kilbane, Sterling Winthrop, 9/27/94.

125. shelf life: Schwartz, ibid, p. 54.

126. Dean Foods: Schwartz, ibid.

126. less than 1%: "Making the Undrinkable Thinkable," Lois Therrien, Business Week, 5/14/90, p. 40.

127. 99% efficient: Interview, Dr. Michael Kaplan, McNeil Consumer Products, 10/31/94.

128. trade press: Schwartz, ibid, p. 54.

128. first lactose-reduced ice cream: Dreyer's and Edy's press release, 4/13/94.

Chapter 9 -- A Cornucopia of Nondairy Alternatives

132. Visser quote & margarine history: Much Depends on Dinner, Margaret Visser, NY: Grove Press, 1986, chapter 3, passim.

134. Cooking Light: "Vitamite Might Be Just Right," Cooking Light, 7-8/93, p. 58.

134. Nutrition Action Healthletter: "Mite-y Mousey," Nutrition Action Healthletter, 9/93, back cover.

134. Vitamite response: "Nutrition Action Healthletter response," undated, provided by Diehl Specialties International.

134. Consumer Reports: "It looks like milk, it pours like milk, but it never came from a cow," Consumer Reports, 11/90, p. 701.

135. Carnation company position: from Helen M. Falco letter, 7/26/90.

137. $17 million sales: Tofutti Brands, Inc. Background Information sheet; "The Marketing of a Dream," Holly Towne, Executive Business Magazine, n.d. [c. 1986], p. 49.

137. $5 million sales: "Tofutti's At It Again: Carrot Yogurt, Anyone?" Food & Beverage Magazine, 9/93.

138. over 30 competitors: Food & Beverage Magazine, ibid; "50 or more," Towne, ibid, p. 50.

138. carrot base:Food & Beverage Magazine, ibid.

141. growing 20% a year: "Cow-ering from Dairy Products: LI Marketing," Judith Schwartz, Brandweek, 5/2/94, p. 54.

141. total sales $100 million: Schwartz, ibid.

141. second-largest crop: Vitasoy promotional literature.

141. John Ruhrah: "Soymilk: Is It a Natural?" Thomas Leonard, East-West Journal, 2/85, p. 38.

141. soy milk not equivalent: "Soy Drinks Not Infant Formulas," FDA Consumer, 6/90, p. 2; "Feeding Baby: Nature and Nurture," Dori Stehlin, FDA Consumer, 9/90, p. 29.

141. Henry Ford: Leonard, ibid.

141. Dr. K. S. Lo: Leonard, ibid; Jan H. Remak, Vitasoy, personal communication, 3/94.

141. food scientists: Tofu, Tempeh, & other Soy Delights, Camille Cusumano. Emmaus, PA: Rodale Press, 1984, p. 118.

143. other vegetable "milks": Food in History, Reay Tannahill. NY: Stein & Day, 1973, pp. 134-7.

146. almost any base: Not Milk . . . Nut Milks! Forty of the Most Original Dairy-Free Recipes Ever! Candia L. Cole. Santa Barbara, CA 93160: Woodbridge Press Pub. Co., passim.

box -- Nondairy Alternatives in Canada

146. "Just say moo," Sharon Bloyd-Peshkin, Vegetarian Times, 11/91, p. 20; News release from Sharon's Finest, 3/4/93; Interview with firm & letter 5/27/94.

Chapter 10 -- Good News from Washington

156. FFDC Act of 1938: "What's in a Food?" Marian Segal, FDA Consumer, 4/93, p. 14.

156. fruit jelly: Segal, ibid.

157. standards of identity: Segal, ibid.

157. all ingredients: Segal, ibid.

158. satisfy state law: Segal, ibid, p. 17.

158. a milk derivitive: Segal, ibid.

158. protein hydrolysates: Segal, ibid, p. 17.

box -- Lactose and caseinate

159. commercial processors: "Utilization of Milk Components by the Food Industry," Dairy Council Digest, 1997;48(5):25-8 (Sept-Oct), p. 25.

159. will not dissolve: Dairy Council Digest, ibid.

159. % lactose: "Galactosemia," Elizabeth Wenz, Ch. 45 in Pediatric Nutrition in Chronic Diseases and Developmental Disorders: Prevention, Assessment, and Treatment, Shirley Walberg Ekvall, ed. NY/Oxford: Oxford University Press, 1993, p. 364.

159. texts on galactosemia: Wenz, ibid.

161. serving sizes: "'Nutrition Facts' To Help Consumers Eat Smart," Paula Kurtzweil, FDA Consumer, 5/93, pp. 26-7.

Table 1 -- Reference Amounts and Equivalents for Dairy Products

163. "The ABC's of NLEA," Gail Rosenbaum Doeff, Dairy Foods, 3/93, p. 17.

Table 2 - Dietary Components Legally Allowable on the New Nutrition Labels

164. Kurtzweil, ibid, 'Nutrition Facts,' p. 25.

165. % Daily Values: -- "'Daily Values' Encourage Healthy Diet," Paula Kurtzweil, FDA Consumer, 5/93, p. 28-32.

165. voluntary components: Kurtzweil, ibid, "'Nutrition Facts,' p. 25.

165. fats: "A Consumer's Guide to Fats," Eleanor Mayfield, FDA Consumer, 5/94, pp. 15-19.

166. omega-3: "Look for 'Legit' Health Claims on Foods," Dixie Farley, FDA Consumer, 5/93, p. 19.

166. national average Calorie count: "Food Labels: New and Improved?" Consumer Reports, 10/92, p. 655.

166. postmenopausal women: Kurtzweil, "Daily Values," ibid., p. 31.

167. other facts: "Honey Bears, Snowmen and Other Exceptions to Food Label Rules," Paula Kurtzweil, FDA Consumer, 12/93, pp. 5-9; "Good Reading for Good Eating," Paula Kurtzweil, FDA Consumer, 5/93, p. 9; Kurtzweil, ibid, "'Nutrition Facts,' p. 27; Doeff, ibid, p. 17.

168. nutrition claims: "A Little 'Lite' Reading," Dori Stehlin, FDA Consumer, 6/93, pp. 12-16; "New Food Labels," Consumer Reports, 7/94, p. 437; "Labeling right may be more difficult than eating right," Maxine S. Lans, Marketing News, 3/2/93, p. 16.

169. health claims: Farley, ibid, pp. 15-21; "Food Label Close-Up," Paula Kurtzweil, FDA Consumer, 4/94, p. 18.

170. calcium claim: Interview with Arlette Belion, FDA Office of Food Labeling; Farley, ibid, p. 20.

Chapter 11 -- Milk on Aisle 1, and 2, 3, 4, 5, 6, ...

173. slightly pareve: "The Why and Wherefore of Kosher," Claudia Dziuk O'Donnell, Dairy Foods, 6/93, p. 69.

174. two meanings: Phone Interview, Union of Orthodox Jewish Congregations, 10/18/94.

174. allergic reactions: "Allergic Reactions to Milk-Contaminated 'Nondairy' Products," James E. Gern et al., The New England Journal of Medicine, 1991;324(14):976-9; "Anaphylaxis in a milk-allergic child after ingestion of milk-contaminated kosher-pareve-labeled 'dairy-free' dessert," Richard T. Jones, Diane L. Squillace & John W. Yunginger, Annals of Allergy, 1992;68:223-7.

Chapter 13 -- Doctors, Diagnoses, Drugs and Diseases

190. increase in summer: Interview, Chuck Angie, Rochester Genesee Hospital Lab Technician, 10/24/94.

191. not typical: Interview, Dr. Robert Kornfield, 2/25/94; see also DiPalma and Narvaez below.

191. a study: "Prediction of Lactose Malabsorption in Referral Patients," Jack A. DiPalma and Roberto M. Narvaez, Digestive Diseases and Sciences, 1988;33:303-7.

192. quote, "less than 30%": DiPalma and Narvaez, ibid, p. 305.

192. quote,"the percent of absorbers": DiPalma and Narvaez, ibid.

box -- Lactose and Medications

192. not impossible: "Lactose Intolerance Associated with Intal Capsules," Robert D. Brandstetter, Rick Conetta & Brian Glazer, The New England Journal of Medicine, 1986;315(25):1613-14.

193. The New York Times: "Pharmacists Help Drug Promotions," Gina Kolata, The New York Times, 7/29/94, p. D2.

194. 18 tests: "Diagnosis of Hypolactasia and Lactose Malabsorption," H. Arola, Scandinavian Journal of Gastroenterology, 1994;29(suppl 202):26-35.

194. only one reaction: "Prospective Comparison of Indirect Methods for Detecting Lactase Deficiency," Albert D. Newcomer et al., The New England Journal of Medicine, 1975;293(24):1232-6; "Use of respiratory hydrogen (H2) excretion to detect carbohydrate malabsorption," Michael D. Levitt & Robert M. Donaldson, Journal of Laboratory and Clinical Medicine, 1970;75(6):937-945, p. 943.

194. 14-21%:"Diagnosis and Screening Techniques for Lactose Maldigestion: Advantages of the Hydrogen Breath Test," Noel W. Solomon, in Lactose Digestion: Clinical and Nutritional Implications, David M. Paige and Theodore M. Bayless, eds. Baltimore and London: The Johns Hopkins University Press, 1981, p. 92.

195. several thousand dollars: Angie interview, 10/24/94.

195. recently on market: Angie interview, 10/24/94.

195. work on hydrogen and CO2: "Respiratory Methane Excretion in Children with Lactose Intolerance," Marvin S. Medow et al., Digestive Diseases and Sciences, 1993;38(2):328-32, p. 329.

195. one-third to two-thirds: "Relationship between Methane Production and Breath Hydrogen Excretion in Lactose-Malabsorbing Individuals," Ramon G. Montes, Jose M. Saavedra & Jay A. Perman, Digestive Diseases and Sciences, 1993;38(3):445-48, p. 445; Medow, ibid, p. 328.

195. methanogenesis correlated: Medow, ibid, p. 328.

195. five criteria: "Diagnostic Tests for Lactase Deficiency," Douglas B. McGill, pp. 35-41 in Milk Intolerances and Rejections, J. Delmont, ed. Basel: Karger, 1983.

196. a few flaws: "Diagnosis of Hypolactasia and Lactose Malabsorption," H. Arola, Scandinavian Journal of Gastroenterology, 1994;29(suppl 202):26-35, p. 29; "Lactose intolerance: Pinpointing the source of nonspecific gastrointestinal symptoms," Ramon G. Montes & Jay A. Perman, Postgraduate Medicine, 1991;89(8):175-84, p. 182; "Treatment of Lactose Intolerance," Janice A. Gaska, American Druggist, 10/15/90, p. 39; McGill, ibid, p. 39.

196. a busy lab: Angie interview, 10/24/94

197. two hours: "Lactose Malabsorption: Optimalization of Investigational Methods," R.-J. M. Brummer, M. Karibe & R. W. Stockbrügger, Scandinavian Journal of Gastroenterology, 1993;28(suppl 200):65-9, p. 65.

197. not very reliable: McGill, ibid, p. 37; Arola, ibid, p. 30.

198. better than BHT: "Comparison of Indirect Diagnostic Methods for Hypolactasia," H. Arola et al., Scandinavian Journal of Gastroenterology, 1988;23:351-7, p. 356.

198. children quote: Arola, et al., ibid, p. 356.

198. elderly diabetics quote: "Concordance of Indirect Methods for the Detection of Lactose Malabsorption in Diabetic and Nondiabetic Subjects," Markus M. Lerch et al., Digestion, 1991;48:81-8, p. 86.

Table 1 -- Advantages and Disadvantages of the Various LTTs

199. Arola et al., ibid, p. 352.

200. lactase assay: Arola, ibid, p.28; McGill, ibid, pp. 35-6.

200. intestinal perfusion: "Quantitative Measurement of Lactose Absorption and Colonic Salvage of Nonabsorbed Lactose: Direct and Indirect Methods," Michael D. Levitt & John H. Bond, Ch. 7 in Lactose Digestion: Clinical and Nutritional Implications, David M. Paige and Theodore M. Bayless, eds. Baltimore and London: The Johns Hopkins University Press, 1981, p. 81; Arola, ibid, p. 28.

200. lactase-sucrase ratio: Arola, ibid, p.28.

200. moderately unpleasant: McGill, ibid, p. 36.

200. footnote 1: doubt the perfection: "Clinical Aspects of Lactose Intolerance in Children and Adults," H. A. Buller et al., Scandinavian Journal of Gastroenterology, 1991:26 (suppl 188):73-80, p. 77; Arola, ibid, p. 26; R.J. M. Brummer, M. Karibe & R. W. Stockbrügger, ibid.

201. once in every 500 biopsies: Arola, ibid, p.28.

201. persuade to leave: McGill, ibid, p. 36.

201. Steven Peiken quote: Gastrointestinal Health, Steven Peiken. NY: HarperCollins, 1991, p. 57.

201. middle-of-the-night: Peiken, ibid, p. 57.

box -- Secondary Lactose Intolerance

202. most common cause: "Treatment of Lactose Intolerance," Janice A. Gaska, American Druggist, 10/15/90, p. 37.

202. more prevalent: "When to suspect lactose intolerance," Theodore M. Bayless, Irwin H. Rosenberg & W. Allen Walker, Patient Care, 9/30/97, p. 138.

202. celiac disease names: The Merck Manual, 13th ed., p. 801;

202. worse symptoms: "The clinical significance of disaccharide maldigestion," Eivind Gudmond-Hoyer, American Journal of Clinical Nutrition, 1994;59(suppl):735S-741S, p. 737S.

202. other causes: "Clinical Picture of Hypolactasia and Lactose Intolerance," K. Villako & H. Maaroos, Scandinavian Journal of Gastroenterology, 1994;29(suppl 202):36-54, pp. 43-45; "The Acceptability of Milk and Milk Products in Populations with a High Prevalence of Lactose Intolerance," Nevin S. Scrimshaw and Edwina B. Murray, American Journal of Clinical Nutrition, 1988;48:1080-1159, pp. 1097-8; Gaska, ibid.

202. Thomas Alvy: Free Yourself From Digestive Pain, J. Thomas Danzi. Prentice-Hall, Englewood Cliffs, NJ, 1984, p. 61.

203. will have both: Interview, Dr. Ricard Lawrence, 9/28/94: 20% of pop will have IBS, 20% of white pop will be LI, so will be an overlap; DiPalma and Narvaez, ibid, p. 306; Gudmond-Hoyer, ibid, p. 737S.

203. no actual correlation: DiPalma and Narvaez, ibid, p. 306.

203. diseases of the intestines: "Lactase Deficiency: Diagnosis and Management," Armand Littman, Hospital Practice, 1/30/87, p. 115; Peiken, ibid, pp. 23-7.

Chapter 14 -- Babies Without Milk: The Lactose Intolerant Child

204. 40 cases: "Small-Intestinal Disaccharidases," Giorgio Semenza & Salvatore Auricchio, Ch. 121 in Metabolic Basis of Inherited Disease, Volume II, 6th Edition, Charles R. Scriver, Arthur L. S. Sly, William Beaudet & David Valle eds. NY: McGraw-Hill, 1987, p. 2988; "Dietary treatment of lactose intolerance in infants and children," Ana Ahab Sinden & James L. Sutphen, Journal of the American Dietetic Association, 1991;91(12):1567-71, p. 1567.

204. footnote 1 -- half in Finland: "Genetics and Epidemiology of Adult-type Hypolactasia," T. Sahi, Scandinavian Journal of Gastroenterology, 1994;29(suppl 202):7-20, p. 9 (gives "few dozen" as world total).

204. footnote 1 -- centers of inborn disease: "A Brave New, Healthy World?", Steve Jones, Natural History, 6/94, p. 74.

205. Temporary LI description: Interview, Dr. Richard Lawrence, 9/28/94

205. greasy stools: "Chronic Diarrhea," Lipsky, American Family Physician, 12/93, p. 1462.

box -- Premature Babies and LI

205. lactase activity in fetus: "Development of Carbohydrate Absorption in the Fetus and Neonate," Munir Mobassaleh et al., Pediatrics, 1985;75:160-6, p. 161; "Developmental Aspects of Carbohydrate Malabsorption in the Premature Infant," John B. Watkins, Ch. 5 in Carbohydrate Intolerance in Infancy, Fima Lifshitz, ed. NY/Basel: Marcel Dekker, 1982, p. 62.

205. don't suffer: Mobassaleh, ibid, p. 162.

205. factors at work: Lawrence interview, 9/28/94.

205. born with sterile guts: Watkins, ibid, p. 68; Lawrence interview, 9/28/94.

206. preferentially attacks: "Rotavirus and Lactase," Ian H. Holmes, Ch. 7 in Carbohydrate Intolerance in Infancy, Fima Lifshitz, ed. NY/Basel: Marcel Dekker, 1982, p. 98.

206. children under two: Holmes, ibid, p. 100.

206. self-limiting: Holmes, ibid, p. 98.

206. restart after week: in Nutrition in Pediatrics: Basic Science and Clinical Application, W. Allan Walker & John B. Watkins, eds. Boston/Toronto: Little Brown, 1985, p. 622.

206. never fully regain: Lawrence interview, 9/28/94.

206. Asian children: Lawrence interview, 9/28/94.

206. scarceness of breastfeeding: Holmes, ibid, pp. 100-1.

206. hands to mouths: Lawrence interview, 9/28/94.

206. several times over: Lawrence interview, 9/28/94.

206. Richard Lawrence: Lawrence interview, 9/28/94.

206. 1%: Lawrence interview, 9/28/94.

box -- LI Tests for Infants and Children

207. collecting bag: Lawrence interview, 9/28/94.

207. nasal prong or infant face mask: "Delta 10 ppm Versus Delta 20 ppm: A Reappraisal of Diagnostic Criteria for Breath Hydrogen Testing in Children," L. Narayan Veligati et al., The American Journal of Gastroenterology, 1994;89(5):758-61.

207. tiny bag -- Interview, Chuck Angie, laboratory technician, Rochester Genesee Hospital, 10/24/94

207. six months and over: Lawrence interview, 9/28/94.

207. under 3 months of age: "Breath Hydrogen Testing in Infants with Diarrhea," Carlos H. Lifschitz, Ch. 3 in Carbohydrate Intolerance in Infancy, Fima Lifshitz, ed. NY/Basel: Marcel Dekker, 1982, p. 33.

207. not accurate first few days: "Low Breath Hydrogen Production in Post-Diarrheic Infants," F. Joseph Jr. & A. J. Rosenberg, Acta Pediatric Scandinavia, 1991;80:792-4, p. 724.

207. stool testing: "Diagnosis & Screening Techniques for Lactose Maldigestion: Advantages of the Hydrogen Breath Test," Noel W. Solomons, Ch. 8 in Lactose Digestion: Clinical and Nutritional Implications, David M. Paige and Theodore M. Bayless eds. Baltimore and London: The Johns Hopkins University Press, 1981, pp. 96-7; Lawrence interview, 9/28/94.

207. HIV babies: "Gastrointestinal dysfunction and disaccharide intolerance in children infected with human immunodeficiency virus," R. H. Yolken et al., Journal of Pediatrics, 1991;118:359-63.

207. infantile colic quote: "Effect of yeast lactase enzyme on 'colic' in infants fed human milk" John J. Miller et al., Journal of Pediatrics, 1990;117(#2,pt1):261-3, p. 263.

208. glucose-galactose malabsorption: "Gastrointestinal Milk-Related Disorders," Joyce D. Gryboski, in Practical Gastroenterology, 1982;6(4):7-12, pp. 9-10; Clinical Gastroenterology, Second Edition, Howard M. Spiro. NY: Macmillan, pp. 499-500.

208. galactosemia: "Galactosemia," Elizabeth Wenz, Ch. 45 in Pediatric Nutrition in Chronic Diseases and Developmental Disorders: Prevention, Assessment and Treatment, Shirley Walberg Ekvall, ed. NY/Oxford: Oxford University Press, 1993; Why Your Stomach Hurts, Gary and Steve Null. NY: Dodd, Mead, 1979, p. 121; Gryboski, ibid, pp. 11-12.

209. general discussion: "Allergy, Intolerance and Other Adverse Reactions to Foods," Robert H. Schwartz, Pediatric Annals, 1992;21(10):654-74.

209. more than 40 proteins: "How allergenic are hypoallergenic infant formulae?" E. Rugo, R. Wahl and U. Wahn, Clinical and Experimental Allergy, 1992;22:635-9; p. 635.

209. two groups: Schwartz, ibid, pp. 655+.

209. IgE associated: Schwartz, ibid, pp. 655.

209. rare, and outgrown: "When to suspect lactose intolerance," Theodore M. Bayless, Irwin H. Rosenberg & W. Allen Walker, Patient Care, 9/30/87, p. 140.

210. food intolerances: Schwartz, ibid, pp. 661.

210. Schwartz quote: Schwartz, ibid, pp. 655.

210. 70% under 2, 10% 7-14: "Epidemiology of Food Sensitivity in Childhood - With Special Reference to Cow's Milk Allergy in Infancy," Stephan Strobel, in Epidemiology of Clinical Allergy, M.L. Burr, ed. Basel: Karger, 1993, vol 31, pp. 119-30; p. 126.

210. before tasted milk: Schwartz, ibid, pp. 666.

210. skin-prick test: Schwartz, ibid, pp. 667.

Table 1 -- Different Reactions to Cow's Milk Proteins

211. Schwartz, ibid, pp. 666.

211. most common food sensitivity issue: Schwartz, ibid, pp. 665.

211. 1-3%: "Treatment and Prevention of Milk Allergy," Stanley P. Galant, The Western Journal of Medicine, 1993;158(6):612-3, p. 612; "Natural history of cow's milk allergy in children: immunological outcome over 2 years," D. J. Hill et al., Clinical and Experimental Allergy, 1993;23:124-31, p. 124 (2-7.5%); Bayless, Rosenberg & Walker, ibid (1%); Schwartz, ibid, pp. 662 (0.3-7.5%); Lawrence interview, 9/28/94 (allergy 1%, intolerance less)

211. 20% of adults: Strobel, ibid, p. 128

211. 20%: "Infant Formula Products," Leisa L. Marshall, American Pharmacy, 1993;NS33(10):55-60, p. 57.

211. AAP-CN: Marshall, ibid, p. 56.

211. most closely regulated: "Feeding Baby: Nature and Nurture," Dori Stehlin, FDA Consumer, 9/90, p. 28.

211. slightly different mix: "Specialized formulas and feedings for infants with malabsorption or formula intolerance," Mary Sue Brady et al., Journal of the American Dietetic Association, 1986;86(2):191-200, p. 193.

box -- Breastfeeding vs. Formula Feeding

212. almost to tedium: "Editorial: Cow's Milk Allergy," D. W. Hide, Clinical and Experimental Allergy, 1993;23:79-80, p. 79.

212. Schwartz quote: Schwartz, ibid, pp. 670.

212. Swedish team quote: "Does Breast-Feeding Prevent Food Allergy?" Bengt Björkstén & N-I Max Kjellman, Allergy Proceedings, 1991;12:233-7, p. 236.

212. editorial quote: Hide, ibid, p. 79.

212. breast is best: Hide, ibid, p. 80.

212. avoid drinking milk: Hide, ibid, p. 80; Strobel, ibid, p. 125.

212. six months: "Atopy Prophylaxis in High-Risk Infants," Merja Kajosaari, pp. 453-8 in Immunology of Milk and the Neonate, J. Mestecky, Claudia Blair & Pearay L. Ogra, eds. NY: Plenum Press, 1991, p. 453.

212. fewer gastrointestinal infections: Hide, ibid, p. 79

213. Three major categories: Marshall, ibid, p. 57.

213. troublesome soy flour: Brady, ibid, p. 193.

213. soy milk not equivalent: "Not Like Mother Made," FDA Consumer, 5/89, pp. 30-1; "Soy Drinks Not Infant Formulas," FDA Consumer, 6/90, p. 2; Stehlin, ibid, p. 29.

213. Galactosemia: Brady, ibid, p. 194.

213. RCF: Brady, ibid, p. 194.

213. lactose-free milk formulas: Interview, Dr. George Baker, Mead Johnson, 10/4/94.

Table 2 -- Varieties of Lactose-Free Infant Formulas

213. USP DI-Volume II, Advice for the Parent: Drug Information in Lay Language, Edition 14, 1994; Mead Johnson, personal communication.

214. very young babies accept: "Management of Infants with Cow's Milk Allergy," Luisa Businco & Arnaldo Cantani, pp. 437-43 in Immunology of Milk and the Neonate, J. Mestecky, Claudia Blair & Pearay L. Ogra, eds. NY: Plenum Press, 1991, p. 440; Marshall, ibid, p. 58.

214. reject when older: Businco & Cantani, ibid.

214. 25%: Bayless, Rosenberg & Walker, ibid.

214. directly on hydrolysate: "Breast Milk and Special Formulas in Prevention of Milk Allergy," Sami L. Bahna, pp. 445-51 in Immunology of Milk and the Neonate, J. Mestecky, Claudia Blair & Pearay L. Ogra, eds. NY: Plenum Press, 1991, p. 448.

214. partially hydrolyzed formulas: Businco & Cantani, ibid.

214. tolerated by 90%: Galant, ibid.

214. every type and brand: "Allergenicity screening of 'hypoallergenic' milk-based formulas," G. Oldæus et al., Journal of Allergy and Clinical Immunology, 1992;90(1):133-5, p. 134; Galant, ibid.

215. Vivonex or Tolerex: Bahna, ibid.

215. unpalatable: Allergies to Milk, Sami L. Bahna & Douglas C. Heiner, NY: Grune & Stratton, 1980, p. 128.

215. 15% of school-age children: "Lactose intolerance can be diagnosed, treated," Better Nutrition for Today's Living, 4/94, p. 20, (quoting DiPalma speech to Amer. Coll. Gastro).

216. pop drinking: Lawrence interview, 9/28/94.

216. 3-4 cans of pop: "Just the Calcium Facts," Bonnie Liebman, Nutrition Action Healthletter, 6/94, p. 9.

216. reduced-lactose milks: "Calcium Absorption and Acceptance of Low-Lactose Milk Among Children with Primary Lactase Deficiency," O. L. Nielsen et al., Journal of Pediatric Gastroenterology and Nutrition, 1984;3(2):219-23; Lawrence interview, 9/28/94.

217. 10-15%: "Lactose Malabsorption and Recurrent Abdominal Pain in Italian Children," R. Ceriani et al., Journal of Pediatric Gastroenterology and Nutrition, 1988;7(6):852-7, p. 852.

217. LI is major cause: "The clinical significance of disaccharide maldigestion," Eivind Gudmond-Hoyer, American Journal of Clinical Nutrition, 1994;59(suppl):735S-41S, p. 737S.

217. one-quarter; 50-60%: "Pediatric Stomach Pain Often May Be Undiagnosed Lactose Intolerance," Judy Glass, Medical Tribune, 11/4/93, quoted in Better Living, ibid.

217. 43%: "Lactose Intolerance and Irritable Bowel Syndrome: Relative Weight in Inducing Abdominal Symptoms in a High Prevalence Area," P. Vernia et al., Gastroenterology, 1992;102(4):PartII/A530, quoted in Better Living, ibid.


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