Transcript: Lactose-free, milk allergy, milk intolerance, explained

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This is the safefood podcast.

James: Hi, I'm James McIntosh, a specialist in toxicology with safefood, and this is the safefood Food Safety Podcast series, where we look at different elements of the food chain on the island of Ireland. In today's podcast, we're going to take a look at an issue that affects quite a lot of people on the Island of Ireland at various stages in their lives. I'm talking about the very broad area of hypersensitivity to milk and dairy products or in essence, milk allergies and milk intolerances.

I'm delighted to welcome Dr. Hazel Gowland, who is currently a member of the expert advisory group on the safefood Knowledge Network. Hazel is one of the leading advocates for patients and consumers with food allergy, particularly severe food allergy, but who am I to tell you about Hazel, when she's right here, so hello Hazel.

Hazel: Hi, James, thank you.

James: Can you give us an idea of your background and the kind of work you're involved in?

Hazel: Yes, I've had a severe nut and peanut allergy since I was very small, and for the last 26 years, I have worked initially voluntarily, and then professionally, and then academically to represent the interests of people with food hypersensitivity, particularly food allergy, which I have myself. And I have become a consumer champion, and an expert and a trainer as well, I train all sorts of people, particularly caterers, other food handlers in managing allergen risks, so that's me.

James: Now today, we're focusing specifically on milk-related allergy and intolerances. But I suppose it's fair to say that a lot of our listeners may still be confused as to the difference between food allergy and food intolerance in general. Hazel, can you just give us a brief, kind of, breakdown of what's the difference is between the two of these? What's the difference? What's the exact difference between food allergy and food intolerance?

Hazel: Well, food allergy is involving the immune system. It involves what they call IgE, is Immunoglobulin E-mediated food allergy. It basically means that your body is sensitised to a protein in the food, and then if it meets that protein again, then your body responds as if it's under attack, and the response involves sending out things like histamine, which you might have heard of, which change the body, make it release fluids from the circulation, causing symptoms, and most symptoms are mild, most symptoms are a bit of an itch, a bit of a scratch, runny nose, runny eyes, but of course occasionally, they can become very serious and you can have your throat closing up and your circulation failing, and sometimes in asthmatic people serious asthma.

So, food allergy is generally speaking faster than food intolerance, and generally speaking has the potential to become more severe. There are different kinds of food intolerances, that are mostly, if you like, gastrointestinal, they're mostly to do with either food not going down nicely, or not going through nicely and causing you trouble, they tend to take longer to develop, and it's therefore a bit more difficult sometimes to find out what the culprit is. With milk, there are some very specific conditions, which used to be called cow's milk intolerance, but they've been better understood in recent years.

So, various versions of what they've now called delayed cow's milk allergy, affect the baby, particularly for babies, the way that their gut absorbs the food, the way that their body responds to the food, so there are various delayed cow's milk allergies. There's also a specific lactose intolerance. Lactose is a sugar that you get in milk and it requires an enzyme in the gut called lactase to digest it, otherwise, you get upset tummy, or diarrhoea, and so on. And some people don't have any lactase, particular populations are a bit short on lactase, Afro-Caribbean people, Chinese people, and many, many other people don't keep that enzyme in their gut, so they have tummy upset if they have lactose. Lactose is just one part of the milk, it's not the protein which causes allergies, it's just one of the sugars.

James: That's very interesting, Hazel, and I suppose, when you think of us, a lot of people when they think of food allergy, they think of peanut allergy, I suppose, because peanut allergies tend to hit the headlines from time to time, and it can be very severe. Can you get a severe milk allergy as well?

Hazel: Sadly yes, some of my research involves investigating fatal reactions to foods, and over the last 30 odd years, I've kept a record of as many fatal reactions to foods as I can, particularly in the UK, and we have as many cow's milk allergy fatalities as we do for peanut. In fact, I just had a look, in the last 20 years, we've had 26 deaths from cow's milk allergy as far as we know, now, we don't always get the full story but suspected or confirmed cow's milk deaths.

There was one tiny baby who was severely compromised, he was very poorly in a nursery, but otherwise there are children from three to 12, about half of them, and then older teens, 14, 15, 17, 18, and then for, if you like, adults, 35 to 50 or so. So, those are people who have died from cow's milk allergy as far as we know. So, definitely cow's milk can kill, it rarely does so, but it can do. Thing about milk is it's a cheap ingredient, people are not as aware about, like peanuts, people well know that peanuts are a problem for some people, but they're not so aware about milk, and it's cheap, it's nutritious, it's everywhere, it's in powder form, it's in liquid form, and it's quite hard to avoid.

James: That's a worrying prospect for anybody who has a milk allergy.

Hazel: Yeah, one of the things is, of course that, the word milk is a four-letter word. The word milk is the legal word that you have to use when you're labelling food or when you're describing food, if you're a food business, and people get confused about it. Milk in law has to come from a mammal, so it has to be from a cow, or a sheep, or a goat or a buffalo, if you're talking about mozzarella or a horse, maybe, but it's clearly defined. The thing is that, two things, people sometimes call milk dairy, and people are very confused about what comes from a dairy and some people think that eggs come from a dairy, or newspapers from the milkman, or orange juice, or whatever.

So, there's a bit of a confusion about the word dairy, and the other is, of course, that there are lots of people now using milk alternatives, they want to use plant-based foods, so they might be looking for almond, or hazelnut, or soy, or something like that, and that can get called milk, but legally, it can't be and it does cause a lot of confusion and confusion is bad for allergic people.

James: That brings us very nicely into the whole area I suppose of allergen labelling, Hazel, and I know milk, for instance, is one of the foods that must be highlighted on a product, a food product's and ingredient label, if it's used as a deliberate ingredient. But of course then there's also, as you just mentioned, the voluntary labelling, that a food business can use if it wants to, if it wants to access a particular niche market, for instance, so labels like milk-free, dairy-free, lactose-free, but they don't all mean the same thing, isn't that right?

Hazel: They certainly don't, no. Lactose-free, means that the product has been treated to remove the lactose and the lactose still leaves the proteins, the casein and the Beta-lactoglobin, the parts of the milk that can cause reactions. So, lactose-free can mislead people who need to avoid the proteins in milk and it might have a severe reaction. Free from, is a bit of a fuzzy area, for gluten, of course, it's clearly defined, you have a 20 parts per million, 20 milligrams per kilogram limit, but for milk protein, you don't have that.

The other problem which is really to the fore at the moment is the search for protein, and the search for alternatives, and plant-based foods in particular, or if you like vegan foods, and I saw a little toing and froing on Twitter last week, where a really leading famous brand of chocolate had brought out a vegan range, and when people with milk allergy started to be interested in it, the company said, "Oh, no, it's not milk-free, we've made it in the same factory where we make the other chocolate and there's a good chance that it may contain milk, so, we put a label on it saying, may contain milk." So, people can't use vegan as code for guaranteed 100% parts per million milk-free.

James: Yeah, I think that's very important, what you've just, especially the case study that you've just described there, Hazel, always read the label, if you have a milk allergy and intolerance, and don't take any chances.

Hazel: Absolutely, yes.

James: Yeah, particularly with regards to milk, as you've said, with modern food processing, milk protein can end up in just about any kind of product now, and it's very important to actually read the label and to take even the precautionary allergen label, the may contain labelling, don't take that for granted either.

Hazel: Absolutely yes, one of the UK fatalities involved the meat from a doner kebab, you know the meat that goes round and round?

James: Yep.

Hazel: And, of course, you never would buy that in your home environment and you wouldn't be preparing it yourself, so you wouldn't know what was in it and people probably just think it's meat, but actually the meat is reconstituted, it's kind of glued together, and sometimes they use yoghurt, and one of the girls that died, one of the young 15-year-old girls had the meat from a doner kebab which had yoghurt in it, and, of course, she didn't know and the restaurant didn't label it or inform her about it, so she didn't stand a chance. So, hidden milk in unusual places, I think they call that functionality, the way that the milk can do a job, a technical job for the product, but actually, it's potentially very dangerous.

James: It's a classic example of how milk protein can end up in a product where you least expect it to be.

Hazel: Absolutely, yes indeed.

James: And it's also, I suppose, a warning for food businesses, to be fully aware.

Hazel: Yes, I think so.

James: Yeah.

Hazel: The more that food businesses understand the consumers' perception and the consumers' thinking, the better really, because these little things, they can really mislead. It is an offense to mislead when you're selling food, but sometimes I don't think people think it through, they don't realize how somebody else might perceive it.

James: It's important to say about, even if you do have something like lactose intolerance or another milk intolerance, your quality of life will be badly affected as well, if milk can be as --

Hazel: I think so, I think--

James: Fatal as a food allergy, but still your quality of life could be, pretty severely impacted, and you really need to take account of the food labels as well, isn't that right?

Hazel: Indeed, but of course, it is stressful to have to read the labels, especially, when, say you have a child and you're giving them into the care of somebody else, and you're not sure that you can quite trust that they get it, and quite often, childcare environments, for example, are switched on to the nut and peanut practice and they may try and have bands and all the rest of it, but you can't man every kind of food and it is very difficult when ingredients are deliberately used, but not really expected, and that can... the quality of life thing is huge, the stress, the kind of guilt on families that they should have done this, and they shouldn't have done that, and all the rest of it, and the tension in relationships about who's doing the better job looking after the person who is allergic, those are really quite significant.

James: The allergen labelling requirements now apply, of course, to foods sold loose, that includes food sold in a restaurant, cafes, deli counters, et cetera, and the ingredients must be highlighted, again in writing, particularly in the Republic of Ireland, the allergen information must be given in written form. In Northern Ireland, this is an optional extra because the information must be imparted orally, isn't that right, Hazel?

Hazel: Well, it can be imparted orally. There still has to be some documentation to support it, but if the business chooses, they can put a sign up, which invites the diner to request the information, sometimes they offer you a folder, sometimes they offer you a printed menu with the allergens on, or they can just tell you, if it's the chef and he comes out and he said, "Yes, I put certain allergens in," but there has to be some documentation to support that behind the scenes, so, it's slightly different.

I think one of my most significant concerns and it was happening anyway, and it has affected, well, it's been part of the problem with some of the fatal reactions, is the increasing use of apps, and online platforms, and online ordering for takeaways, delivery food, and even restaurant food now, people can order that in advance, and the technology has to keep up with the needs of the people with food hypersensitivities. So sometimes, it's very easy to declare your allergy and to get that message through to the kitchen, and then they know you're coming and all the rest of it, but in some cases, that doesn't work, and it has been part of the cause of some of the fatal reactions that we've had. That the person who was ordering the food, tried to declare their allergy but didn't get the message through to the people preparing the food.

So, it is quite an issue and making sure that you can have some direct contact with the people in the kitchen, ideally, to make known what your needs are is very, very important, and also the reassurance that they got the message and they've understood, 'cause otherwise it's quite scary. But it does concern me somewhat, and in the pandemic as well, there's more and more online ordering, that there is an extra risk for people with food hypersensitivity.

James: But the obligations are still there, you must provide the information, is that right? At that point of presentation, sale, or supply also to that effect.

Hazel: Yeah, indeed it is, it's the point of choice. So when you're choosing your food, you should be able to find out at least what those 14 allergens are, and of course, ideally, be able to have a conversation or some way of communicating that you need them to think, may contain as well, and then of course, at the point of delivery, not least, because we need to make sure that you, the allergic person get the right meal, ideally, they've put a sticker on it, or a label, or saying, "This is the one that we've taken extra care with, 'cause this is the one for you."

James: Hazel, if some of our listeners want to get more information on milk allergy specifically, milk allergy and milk intolerances, particularly the different kinds of milk intolerances, what's a good source of information for that?

Hazel: Well, I can send you a link for some very useful information from the Anaphylaxis Campaign, now, that's a UK charity, but I think a lot of people across the Island of Ireland are very familiar with their work, and also, on the subject of weaning and early food, particularly for allergic babies, there is a very, super new document from Allergy UK, so, I'll send you the links to those and then you can put them on your website or the appropriate place.

James: And of course, there's a lot of allergen information on the safefood website, and particularly for food businesses. There's also a lot of information on the websites of both the Food Standards Agency in the UK and Belfast, and in the Food Safety Authority of Ireland, in Dublin as well. Well, we have got to leave it there, thanks to Hazel for the exploration of milk allergy and intolerances, which as I said affect many people on the Island of Ireland and can be very serious indeed, and thanks to you, our listeners for tuning in. If you have any comments on today's podcast or you wish to ask a question on this issue, then do get in touch with us by email on [email protected]. There are other podcasts in this series, so you can search for these safefood podcasts wherever you normally get your podcasts, or join the conversation on Twitter @safefoodnetwork, or follow us on LinkedIn. So, until next time, goodbye and take care.

That was a Food Safety podcast presented by James McIntosh, specialist in toxicology with safefood.