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NHS under pressure, Breast cancer prevention, Lactose intolerance

Do funding requests hinder NHS operations? A new genetic test that can identify women at risk of breast cancer more accurately, and how common is lactose intolerance?

Do funding requests hinder surgery on the NHS? GP referrals to specialists for common complaints are checked by a panel to make sure they're appropriate, but can the admin for funding requests be more costly and time consuming than the operation itself? Mark Porter meets an eye specialist in Reading who argues that it can. Plus a new genetic test that has been developed to identify women at risk of breast cancer more accurately. And lactose intolerance: there's a burgeoning number of lactose-free ads and products in the shops, but is need driving the market - or marketing driving the need?

Available now

28 minutes

Join us in the BBC Radio Theatre in London on 8th February 2017!

BBC Radio 4’s Inside Health is hosting a special debate on the current state of the NHS. Dr Mark Porter and guests discuss what needs to give.

The last few months have seen the service creaking under unprecedented demand, and there is likely to be worse to come.  Something needs to give. Is it simply a matter of more resources, or do we also need to change our expectations of what the NHS provides? Is rationalisation and rationing the way forward? 

Mark is to discuss the issues with a panel including regular contributor Margaret McCartney GP, Claire Marx, president of the Royal College of Surgeons, and Chris Hopson, chief executive of NHS Providers.

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Submit a question for the panel by following the links below or on the ‘Contact Us’ tab above

Programme Transcript - Inside Health

Downloaded from www.bbc.co.uk/radio4

 

THE ATTACHED TRANSCRIPT WAS TYPED FROM A RECORDING AND NOT COPIED FROM AN ORIGINAL SCRIPT.  BECAUSE OF THE RISK OF MISHEARING AND THE DIFFICULTY IN SOME CASES OF IDENTIFYING INDIVIDUAL SPEAKERS, THE BBC CANNOT VOUCH FOR ITS COMPLETE ACCURACY.

 

 

INSIDE HEALTH

 

Programme 3.

 

TX:  17.01.17  2100-2130

 

PRESENTER:  MARK PORTER

 

PRODUCER:  ERIKA WRIGHT

 

 

Porter

Coming up today:  Lactose intolerance – if you believe the ads and the glossy mags, lactose appears to be the latest nutrient to avoid if you are prone to rumbly guts and feeling a bit under the weather.  But what does the science say?

 

And preventing breast cancer – NICE already advocates offering preventive drugs like tamoxifen to women most likely to develop the disease, but how should we identify them? I meet the man behind a new, more accurate method.

 

Clip

If you went to your doctor and they said you’re at high risk of a heart attack come back in a year and we’ll see if you’ve had one, wouldn’t be too happy.  But that’s in fact what we do in breast cancer now.

 

Porter

More on breast cancer prevention later.

 

But first a subject that is likely to touch most families at some stage. We all know the NHS is under pressure – it’s hard to miss it at the moment.  Rising demand and finite resources mean it has had to cut its cloth accordingly and limit the treatments it offers.  One way to do that is to scrutinise all GP referrals to specialists to check that they’re appropriate, and for conditions that the NHS is happy to fund.  Such third party scrutiny made the headlines this week following concerns that it may slow down care for some cancer patients, but the repercussions affect far more common and less sinister complaints too.  Complaints like bunions, varicose veins, and hernias – all of which are often no longer eligible for surgical treatment on the NHS in many parts of the UK.  And those three are just the tip of a growing iceberg as the bar for eligibility for care is raised ever higher in an attempt to rationalise services.

 

Dr Margaret McCartney is in our Glasgow studio. Margaret, let’s start with the GPs’ referral – who’s checking that?

 

McCartney

Well it depends where you live.  So in some areas referrals like this may go to a private company working outside the NHS but contracted to the clinical commissioning group to scrutinise referrals.  And what that means is a decision maker in that organisation may decide that that procedure won’t get done at all, so the patient doesn’t get seen – a letter goes back to the GP saying we’re not seeing that patient.  Or they may say we want more information or they may say we’re going to refer you somewhere else, to somebody else for some other procedure or some kind of holding test or mechanism.  The referral is not guaranteed to go through.  In other areas that referral might be looked at by a consultant or a specialist within the department the GP’s referred to.  In other places it might not be looked at all – the patient just might be sent an appointment for an outpatient discussion about what would happen next.  So there is huge variability.

 

Porter

Well let’s assume it gets through that first hurdle.  The patient gets to see the specialist, they’re sitting there, the specialist says oh I think you need treatment X but this treatment’s not normally funded, it’s one of the ones on the list that the CCG are reluctant to find – what happens then?

 

McCartney

Yes and there are these exclusion lists.  So in 2011 most primary care trusts had published some kind of exclusion list and now this is in charge of CCGs in England and in Scotland we’ve got these exceptional referral forms that we have to do for things that are said to be not normally funded by the NHS.  These cases, there are lots of rules around them, but essentially the general practitioner or the consultant has to make an application to a panel to ask for treatment for this patient based on exceptional circumstances.

 

Porter

Now we can all understand why some treatments might not be normally funded – there might not be an evidence base behind them, patients might not need them, they might be self-limiting – lots of different reasons.  But if a consultant surgeon looks you in the eye and says you need an operation you can imagine the patient thinking that would be enough.

 

McCartney

And it’s not, that’s the problem and part of this is of course driven by the financial squeeze that so many organisations are under, they’re looking for ways to save money.  Part of this was also driven a few years ago with having independent sector treatment centres where people could be sent to different places to get procedures done supposedly cheaper or in higher volume and supposedly lower cost – didn’t of course work out like that.  So these mechanisms were designed to send people in different directions.  And now the same mechanisms are being used to say actually we’re not going to fund that procedure at all.

 

Porter

So the specialist or me, as his GP or her GP, sends in an application – a funding request – for an exceptional case.  It’s looked at by another panel, now who’s on that panel, is it full of surgeons?

 

McCartney

That’s a very good question.  So again immense variability.  So there has been studies done on this, there was a publication in the BMJ in 2011 trying to find out who made up these panels.  There certainly always seems to be clinicians on the panels, not necessarily specialists within that area, there are often managers on it and there seems to be in some areas, at least, a lay representative – so a patient representative on – but certainly not on all of these groups.  So immense variability.  I have to say in Scotland it tends to be that the rules are fairly evenly applied, whereas in England with so many CCGs applying slightly different rules you could be having an operation that would be denied to your neighbour across the road and down the street if she lives in a different area.  We have to remember again NICE was set up to try and reduce variability, reduce this postcode prescribing, but all that’s happened with the most recent healthcare reforms in England is that it’s made it actually worse rather than better.

 

Porter

The criteria set out on these forms may well fit from a population point of view but they don’t actually always work when you’re faced with an individual across the consulting room.

 

McCartney

Yeah and this is a consequence of this tick box, industrial medicine that we have that’s been forced upon us where individual circumstances seldom get an adequate look in and I think it’s one of the tragedies of modern medicine is that we try to put people into these very tightly defined boxes – human life and human suffering and symptoms are usually much more complicated than that.

 

Porter

What happens to these patients if they’ve had their treatment turned down after being told by a specialist that they need it – their GP’s referred them and they’re left in limbo presumably are they?

 

McCartney

Well they absolutely are and the costings – what’s never factored in to these equations is the stress, the anxiety, the paperwork, the bureaucracy, the uncertainty that people have to live with.  And of course they may save money in the short term but what happens in the longer term – do people eventually need surgery anyway, do emergencies result as a consequence of not treating things in planned elective way – is this doing more good than harm, is this actually costing us far more?  There are so many uncertainties about this.

 

Porter

Well to find out how this is affecting the care of patients with common complaints that are no longer automatically eligible for hospital treatment, I went to Reading to meet eye surgeon Andy Pearson, who has a special interest in eyelid problems.

 

Pearson

We’re seeing restrictions coming in on some of the conditions that we’d have previously been able to treat without any difficulty.  Here we’re talking about benign, non-malignant type of problems.  So a common example would be like a meibomian cyst, it’s also called chalazion, which is a cyst of the oil glands that live in the eyelids.  And these frequently become blocked and then get inflamed and the patients end up with a sort of large inflamed lump on their eyelid.  Which doesn’t sound too terrible but the difficulty is with these things they’re often very persistent and patients get utterly fed up with them and these are conditions which we’re now struggling to be allowed to treat.

 

Porter

So going back a few years if I, somebody like me, referred that patient up because they’re having trouble, you decide that they need some sort of procedure, you’d have just gone ahead and booked them in, would you?

 

Pearson

Absolutely, yeah, we had a great system before, where we had a clinic where these patients could come for a one-stop service.  So they would be referred in, they’d arrive, they’d be assessed, there would go straight through to have their treatment on the very morning or the afternoon that they were seen.  It was a great service – you got through lots of patients, the patients were very happy.  It’s all gone, that’s become a real issue now.

 

Porter

It strikes me as – it’s not exactly an expensive procedure.

 

Pearson

That’s right yes, I mean I suspect that the cost of administrating the kind of agreement to go ahead with these kind of procedures is much more than is the cost of the procedure itself.

 

Porter

So I come and see you, I’ve got a big intermittent boil effectively in my upper eyelid, you would have sent me through your one-stop clinic, now what do you have to do?

 

Pearson

So there’s a funding committee, there’s a form to be filled in, this is done by a clinician.  That then goes back to a panel and then they have to assess the information that’s provided to them in this form, asking about the impact on the patient’s life and why you feel this particular patient should have treatment, as opposed to all patients with this treatment.  There’s a word ‘exceptionality’ that’s in there.  So you have to describe what it is about this particular patient that makes them exceptional and why they should, in particular, have treatment when other patients with the same condition aren’t as needing to have that treatment.

 

Porter

But why put these hurdles effectively in place in the first place?  I mean you used to see people and say well you need to have something about this.  The condition hasn’t changed.

 

Pearson

No the condition’s very much the same, very common.  I think reasonably enough the NHS can be seen not to be funding what people might consider cosmetic treatment.

 

Porter

That’s the basis that we hear in general practice is that the lump on your upper eyelid it’s not nice but it’s not the end of the world and having it done is cosmetic.  Is that correct in your opinion?

 

Pearson

In some situations yes it may be cosmetic but there are other situations where actually it’s far from cosmetic – it maybe in the centre of their top eyelid, it may be pressing the eyelid down, it maybe impairing their vision either through the pressure or possibly through causing astigmatism, in other words a blurring of their vision that’s not correctible with their normal glasses.  So a lot of the patients that are coming through are not complaining about these being cosmetic issues, nevertheless they are being treated as if all of them are cosmetic.

 

Douglas

My name is Douglas and I have had a chalazion cyst on my eye for over a year.  Initially I thought it was just a stye but when it got infected I went to the GP, she confirmed it was a chalazion cyst and gave me the appropriate antibiotics.  And after several months living with this, as you do with these things, the chalazion got very badly infected the second time, I mean literally my eye was out like I’d done a couple of rounds with Mike Tyson.  The infection happened over the weekend, I went into A&E and they don’t need me at this time of year, with my eye out like a golf ball quite literally shut, I couldn’t see.  I again was given some antibiotics and I was told that I would be fast-tracked because it did look quite severe.  Of course that didn’t happen.  What happened next was the GP called me to say that they had to apply for funding as it was deemed cosmetic and to me it wasn’t about being cosmetic, it really was affecting my vision.  I felt I couldn’t drive, I had two days off sick.  I do finally have an appointment and quite frankly I thought the whole procedure was lost in red tape.

 

Pearson

I think the main difficulty with this is it’s all labelled cosmetic but it isn’t.

 

Porter

Left to its own devices what’s the natural history of this – does it go away?

 

Pearson

So a condition like a meibomian cyst or a chalazion typically will go away but one of the difficulties is they’re so stubborn.

 

Porter

In terms of admin is it an extra burden for you and your team?

 

Pearson

Yeah this is a big one actually.  I mean I think the amount of extra administration around these issues is really substantial.  The cysts are common, so there’s immediately a lot of patients with this condition, and the time it takes to look after all these forms and to go through the whole process I’ve no doubt it takes an awful lot longer than it would do to actually get on and just do the procedure in the first place.

 

Porter

Eye Surgeon Andy Pearson making a point I suspect our interviewee Douglas would wholeheartedly support.  And, just to be clear, Douglas is not a patient of Mr Pearson, but faces similar hurdles in another part of England.

 

We will be returning to this issue soon when we investigate the impact on hand surgery, but are keen to hear the other side of the argument too.  We have tried, unsuccessfully, to encourage someone from a clinical commissioning group (CCG) to come on to Inside Health to tell us about it, but we are not going to give up.  There is a need for rational spending of our limited resources and we understand that so if you work for a CCG or are involved in appraising, and rejecting or approving referrals, then why not come on the programme and share your views.  Tempted?  Email us at insidehealth@bbc.co.uk.

 

It is nearly three years since NICE first recommended the use of drugs like tamoxifen to prevent breast cancer in women at high risk of developing the disease.  But how do you identify who will benefit? 

 

The conventional method is based on family history profiling but won’t pick up every high risk woman. And others it does identify, may be offered preventive therapy they don’t actually need.  What is required is a more accurate tool that can be offered to all women attending routine breast screening clinics.  And that is exactly what has been developed using a method that combines family history, mammogram findings, and genetic profiling.

 

Early studies suggest it is more accurate than existing methods, and could identify thousands of women who are currently slipping through the net, as well as reassuring many others who are not at as high as risk as previously thought.

 

Professor Jack Cuzick is Director of the Wolfson Institute of Preventive Medicine and part of the team that developed the new tool.

 

Cuzick

Breast cancer is the first cancer in which we’re getting to the position that the cardiologists were at some time ago and that is we don’t wait for disease to happen.  If we identify someone at high risk we can actually offer preventive treatments.  And we’ve spent the last 20 years developing those.  We now have treatments which are quite effective and prevent really half of breast cancer.

 

Porter

So you use a cardiologist analogy there.  I mean presumably you’re referring to statins being used to protect against heart disease and stroke for instance.

 

Cuzick

Absolutely.  If you went to your doctor and they said you’re at high risk of a heart attack, come back in a year and we’ll see if you’ve had one, wouldn’t be too happy.  But that’s in fact what we do in breast cancer now.

 

Porter

Okay, so first of all we have to identify the women that are at high risk.  So how are we doing that at the moment?

 

Cuzick

Standard factors for risk have been incorporated into a model that we use routinely and they’re essentially family history – if you’ve had a mother or a sister with breast cancer under the age of 50 your risk is almost doubled, if you’ve had two breast cancers in the family your risk is more than doubled.

 

Porter

So at the moment we’re principally basing this concept of high risk on family history, how can we confirm what’s going on, what do genes bring to the party?

 

Cuzick

We’ve discovered over a hundred genes, which individually don’t increase your risk or decrease it very much, maybe 10% up or 10% down.  But we’ve used 88 of these now in a profile and once you have 88 of them it creates a spectrum of risk where some women really are at high risk and some are at a lower risk and we think that that’s very useful in terms of assessing who needs preventive therapy and also beginning to think about tailoring the regularity with which you go for screening according to what your risk is.

 

Porter

So how would you see this new test being used – is it being offered to every woman or just the women that register as being high risk on the questionnaire?

 

Cuzick

We think that it should be done routinely.  It’s not an expensive test.  The three factors or essentially the questionnaire factors, these genetic factors and also what’s called mammographic density, which is detectable on your mammogram, the mammogram tells you more than whether you have breast cancer now but it tells you a lot about risk.  We think these things should be routinely measured and women should be told about them when they first come for screening, which is between 47 and 50 now.

 

Porter

So a woman’s identified at high risk, what’s likely to happen to her?

 

Cuzick

NICE have already recommended that preventive therapy should be offered for women who have more than an 8% 10 year risk.  And we can find about 2-3% of the population in that group.  They also say that for women between a 5 and 8% 10 year risk, which is a much larger group, it’s about 10-15% of the population, it should be discussed.  So our approach would be to identify those women, to talk to them about preventive therapy.  For women that have a slightly increased but lower risk preventive therapy’s probably not appropriate but there are other things – more exercise, watching your weight, being aware of the risks associated with hormone replacement therapy.

 

Porter

And to put that risk in context when you talk about a 5% risk over 10 years what you’re saying is that somebody’s got a 1 in 20 chance of getting a breast cancer in the next decade?

 

Cuzick

Correct.  And that’s about twice the average risk for a 60 year old woman.

 

Porter

And how effective is preventive therapy – once you’ve identified these women and you do something about it does it work?

 

Cuzick

There are two drugs that have been shown very clearly to work.  One is tamoxifen, which works for pre- and post-menopausal women, so it’s a good option for younger women at an increased risk.  And we’ve recently shown that if you take tamoxifen for five years your risk of breast cancer’s reduced for at least 20 years by about a third.  For the post-menopausal women more recently we’ve been looking at a drug called anastrozole, which is an aromatase inhibitor.  It’s essentially replacing the use of tamoxifen for post-menopausal breast cancer and it has a reduction in risk of more than 50% but the follow-ups only about seven years on those, so the long term effects are not so clear yet.  But that looks to be the first option for post-menopausal women.  Taxmoxifen is the only serious option for pre-menopausal women.

 

Porter

So what do you think is going to happen next?  I mean assuming everything goes well in the pilot.

 

Cuzick

Well I would hope that this would be rolled out in three to five years.

 

Porter

Professor Jack Cuzick.  And the more I think about his comparison with statins and heart disease, the more this initiative seems to have in common - and no doubt similar debates over the benefits versus the side effects will rage for just as long. There is a link to Professor Cuzick’s research on the Inside Health page of the Radio 4 website.

 

Now what do you know about lactose intolerance?  It’s a sensitivity to the sugar found in milk and dairy products, but much of what most people understand is likely to be based on the burgeoning number of ads for lactose-free products, and features in the glossies, outlining the potential benefits for anyone prone to an upset stomach. But is need driving the market - or marketing driving the need?  Dr Margaret McCartney has her doubts.

 

McCartney

Lactase is the enzyme that’s produced in your small bowel and that digests lactose which is the chemical compound that’s the carbohydrate within milk and lots of other dairy products as well.  And the problem is that some people don’t have this lactase enzyme.  People of Chinese, Asian, African descent are more likely not to have lactase and are going to be much more likely not to be able to digest the milk carbohydrate lactose.  And rather than naming people that don’t have this enzyme as lactase deficient some people think that the Northern Europeans that can digest milk okay, should actually be called lactase persistent people.

 

Porter

So lactase deficiency is the norm in the rest of the world but here, in the UK, because we’re largely of North European descent we’re the least likely to have a problem with lactose?

 

McCartney

Yes because we’re the exception rather than the rule or I am anyway.

 

Emmanuel

My name’s Anton Emmanuel, I’m a gastroenterologist at University College Hospital in London.

 

Lactose intolerance is something which is in one’s genes and therefore it’s very prevalent in certain populations, in Sub-Saharan Africa and sort of East of the Caucasian mountains.  So with migration patterns we’ve ended up with a population in the UK in certain regions, especially in metropolitan ones.

 

Porter

Looking at the UK as a whole I mean it’s quite a hotchpotch of mix of genes, people coming from different ethnic backgrounds, what’s the sort of excepted figure amongst gastroenterologists for the likely prevalence of lactose intolerance?

 

Emmanuel

So what we have in the population in the UK is about 20% of us who believe we’re lactose intolerant, hence the reason why we’re seeing more of these products in our supermarkets.  If you look at that 20% who are intolerant from their subjective feeling and do a lactose test on them only a fifth of them, in other words 20% of that 20% are truly lactose intolerant.  So actually the prevalence of the genetic abnormality is still comparatively rare.

 

Porter

So what’s happening to the rest of those people then who think they’ve got some sort of milk intolerance but it’s not related to lactose?

 

Emmanuel

The other four-fifths of that 20% are not lactose intolerant but they may feel sensitivity to drinking milk.  It can be due to the fact that they are maybe sensitive to the protein component of milk or it can be due to the fact that they are almost anticipating getting symptoms with milk and therefore the brain is a very powerful thing when it comes to food intolerances and we sometimes find it very hard in gastroenterology practice to truly isolate symptoms being caused by foodstuff, given how much anticipation there is.  And marketing is a very powerful trigger to the brain to say oh I’m doing something, I’ve purchased something, it’s helped my next door neighbour therefore it should help me.  And that isn’t always the case.

 

Porter

It’s all capitalising on the placebo effect – if you think it’s going to be doing you some good it might well be doing you some good.

 

Emmanuel

And we mustn’t underestimate that in terms of its importance in making people better but you must also be careful not to bankrupt people as they go around trying to find the perfect foodstuffs when it isn’t probably their food that’s causing all their symptoms.

 

McCartney

I was in the hairdressers at the weekend trying to relax when I saw not only adverts for things like soya milk, almond milk, oat milk, rice milk, hazelnut milk but even a feature saying how I could have wonderful skin and I could make my energy levels so much better by avoiding all dairy products, to avoid lactose.  And I really think it’s ridiculous because it was being marketed at people who do not have lactase deficiencies, really trying to medicalise us and offer us a problem that we don’t have because if you’ve got the enzyme you can’t have a problem with it.  So certainly there are some people who are intolerant of things, you know that’s absolutely fine, try things, see if it works for you but the idea that you can be marketed out and told that you’re going to somehow feel miraculously better by spending much more on your food I think has lots of errors attached to it.

 

Porter

I’m well aware how agin you are marketing campaigns based on pseudo-science but does it really matter, I mean if somebody here is using lactose free milk and they’ve not actually got a lactose problem, I mean it’s not like a harmful intervention, it’s not like they’re taking a drug?

 

McCartney

Yeah I mean there is that but I mean I suppose it’s number one, thinking that you’ve got a problem when you don’t, so giving the wrong label to your symptoms might mean that you make choices that you wouldn’t necessarily have done had you had a better option.  They tend to be much more expensive and it could lead you to restrict your diet in other ways.  So, for example, a lot of hard cheeses, like cheddar, Edam, parmesan, they have very little lactose in them, so you’re unlikely to develop a big problem.  And even people who have got lactase deficiency can digest a degree of lactose containing foods, it doesn’t tend to be all or nothing.

 

Emmanuel

It’s the dose phenomenon – none of us are purely lactose deficient or purely lactose tolerant – we’re all on a scale of this.  Milk is a complicated compound, milk is actually a mixture of carbohydrate, fat and protein and the carbohydrate or sugar part of that is lactose.  And so if one doesn’t have the right genetic makeup one doesn’t produce enough of this enzyme lactase then we don’t break down that sugar part – lactose – and therefore that sugar then persists into our colon and sugar in our colon is a lovely combination for giving us diarrhoea because out gut bacteria start chewing it up and give us rumbly tummy and loose stools.

 

Porter

So is that sort of picture – the rumbly tummy and loose stools – is that all that lactose intolerance can present with?

 

Emmanuel

Those are the gut symptoms, there are symptoms beyond the guy and this is where the story gets more interesting.  So there is some evidence that people can get cognitive problems, they can get slightly slower or more muzzy in their thinking, there are effects where it can seemingly even become more vulnerable to acute infection.  But that’s unusual.  We can test for lactose intolerance formally, that’s usually done with something called a breath test, where somebody comes along to hospital and then gets given a dose of lactose sugar and then we collect their breath sample over two to three hours thereafter and look for a rise in a gas called hydrogen and if that’s present then we know they’re lactose intolerant.  The problem with the test is that it’s rather dependent upon how much of a dose one gives.  To any normal person if we give enough lactose we will cause intolerance.  If you give somebody say 100 grams of lactose which is about four or five kilos of camembert for example, they would get looseness and rumbly tummy.  So it’s a question of dosage.  And some testing uses very large doses of lactose, some testing uses more rational doses.  So the testing isn’t a gold standard.

 

McCartney

What you really want is a trusted dietician to take you through things if you’ve got a problem with your foods because it can be quite difficult to eliminate things, see whether or not you’ve got symptoms, reintroduce things, see if the symptoms come back.  If I was having problems I’d probably want to speak to an NHS dietician to get some really good evidence based advice.

 

Collins

I’m Catherine Collins, I’m a spokesperson for the British Dietetic Association and I’ve been an NHS dietician for over 30 years.  There’s two parts of food exclusion.  The first is to cut out the offending foods that you think might be triggering the symptoms.  And the second, as a dietician, is to make sure that nutritionally the diet isn’t compromised by cutting out those foods or good group.  So in terms of lactose intolerance the simplest thing would be to say to people cut down or cut out your cow’s milk or goat’s milk or sheep’s milk, any animal milk will contain lactose, and to swap instead for soya milk, preferentially, because soya is a very good quality protein and it’s fortified with calcium and nutritionally is very similar to an animal milk.  I would never recommend that people use the plant milks, apart from soya, so potato, rice, coconut, almond milks, they’re not rich in protein, they not nutritionally equivalent to cow’s milk or soya milk.  So in trying soya milk instead of cow’s milk for a week or two if you notice an improvement in your symptoms it is highly likely that you may be lactose intolerant but the important thing there is that you must re-challenge, you can never just cut out a food out and say that’s it forever.  The brain and the gut are very closely linked, so perhaps if you’re very worried about lactose or worried about diet and you make some changes that you perceive to be positive then perhaps that makes you feel better.  So you should try that food again and see if you evoke the same symptoms you had when you had it originally.  And if that’s the case it’s probably likely you do have a lactose intolerance. 

 

The amount that you take is also important because we actually know from research – we know that a large number of people that are actually lactose intolerant can tolerate milk without any symptoms whatsoever.  There’s been studies done that have actually measured lactose intolerance by using the breath test and shown that those people theoretically shouldn’t be able to tolerate milk but they can.

 

Porter

And when you say they can have a bit of milk, I mean what are we talking about?

 

Collins

A lot of people with lactose intolerance can take milk in tea and coffee quite easily without any symptoms whatsoever or they can take a yoghurt, especially if it’s a yoghurt that’s a live yoghurt, one containing live bacterial cultures because the bacteria there can break down the lactose for you before you actually consume the product.  But if you’re a person that’s perhaps into sports training, doing a lot of exercise, taking whey based supplements or having fortified protein drinks, which use milk powder added to a milk base, then the amount of lactose present per dose might be sufficient to cause you that bloating and abdominal pain afterwards.

 

Porter

So going back to our person who thinks they’ve got a problem, they’ve excluded milk products for a few weeks, their symptoms have got better, they’re now reintroducing them, do they reintroduce everything?

 

Collins

I’d suggest reintroducing gradually.  If you introduce a small amount in tea or coffee or you have a small amount on cereal, just enough to coat it, so you can get your cereal down without having it dry, then you can move on to having slightly more.  And what’s heartening here is that the majority of people, even with a genetic tendency to not be able to digest lactose, can actually train their bowel to be able to take milk.  It’s been done really successfully in America where a lot of African American girls have a very low calcium intake and studies have shown that actually getting them to drink milk regularly helps their intestine develop a way of coping with the milk.  So they can include milk in their diet without any symptoms.

 

Porter

Dietician Catherine Collins.  As ever there’s a link to more information on lactose intolerance on our website.

 

Just time to tell you about next week when we will be taking a closer look at the research behind claims that one in 25 deaths in NHS hospitals is preventable.  And I visit one of the UK’s oddest storage facilities – a poo bank.  And, trust me, there isn’t a teddy bear in sight.

 

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