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Lactose in processed foods: evaluating the availability of information regarding its amount.

Introduction

Lactose is the primary carbohydrate found in milk. It consists of two monosaccharides, glucose and galactose, characterizing a disaccharide. Lactose intolerance consists of poor digestion and absorption of lactose from the reduced activity of the [beta]-galactosidase enzyme, also known as lactase, which can hydrolyze lactose to glucose and galactose (1). Individuals with lactose intolerance are unable to digest lactose, which will not consequently be absorbed into the small bowel. When reaching the colon, lactose is fermented, producing short-chain fatty acids and the formation of gases (carbon dioxide, hydrogen and methane) by the intestinal microbiota (2), which can cause gastrointestinal problems, discomfort and symptoms, such as nausea, colic, flatulence, diarrhea, bloating, abdominal pain, among others (3). Usually, these symptoms start around 30 minutes to 2 hours after consumption of some food containing lactose (4).

Lactose intolerance can be classified into three types: congenital, primary and secondary. The congenital is caused by the complete absence of jejunal lactase throughout the life of an individual and is detected at childbirth. The primary type can develop at any age and is caused by the declining concentration of lactase in the human body, genetically programmed (non-persistent lactase), from infancy to adulthood, leading to difficulties in the hydrolysis of lactose. The secondary type occurs due to the presence of intestinal lesions or diseases and is transient and reversible (5).

The persistence of lactase (or lactose tolerance) in different populations seems to be associated with the domestication of dairy cattle and with the habit of consuming milk after weaning (6) and, therefore, the prevalence of lactose intolerance varies according to the geographic region and habits of the population.

A study points that non-persistence of lactose, or lactose intolerance, is found in 65% of the world's population (7), affecting around 2% to 15% of people of North European descent, 60 to 80% of blacks and Latinos, and 80% to 100% of Native Americans and Asians (5). In Brazil, a study showed that the prevalence of primary lactose intolerance in adults in a sample of 567 subjects was 57% for whites and mulattos, 80% for blacks and 100% for Japanese (8). Other studies indicate a high prevalence in the Brazilian population: 44.1% in 1,088 individuals in Southern Brazil (9) and 60.8% in 115 individuals in Southeast Brazil, of which 53.2% in whites and 91.3% in nonwhites (10).

A reduction of at least 50% of enzyme activity is required to trigger the symptoms resulting from the primary deficiency of lactase, which explains part of the variation in tolerance to small doses of lactose by individuals with lactose intolerance. Another possible explanation is the adaptation of the intestinal microbiota (11).

Studies show a variation in the amount tolerated between 7 and 15g of lactose per day (11-13). A study conducted by Vesa et al. (14), showed that individuals with lactose poor digestion did not evidence gastrointestinal symptoms induced by the ingestion of low amounts of lactose (0.5 to 7.0 g/day).

Therefore, concerning nutritional treatment, it is recommended to avoid the consumption of products containing a high amount of lactose or to perform the ingestion of the enzyme lactase with dairy products. It is also possible to consume dairy products in which the amount of lactose has been reduced by fermentation, such as yogurt or curds, or excluded by industrial processes, such as processed foods without lactose (15,16). The inadequate nutritional planning or replacement of milk and dairy products with their respective lactose-free products may lead to a lower intake of calcium, phosphorus and vitamins (15).

There is evidence of a high consumption of processed foods in contemporary society (17), and a stimulus to the intake of diet/light/zero foods (18). Thus, because of the tolerance of a certain amount of lactose by individuals with lactose intolerance, information on the presence and amount of lactose in processed food labels should be mandatory in Brazilian legislation on nutritional labeling of packaged foods. However, such legislation does not require the provision of such information (19).

According to the National Health Surveillance Agency (ANVISA), lactose-free or low-lactose products should be labeled according to the specific regulations for special-purpose foods (20). However, even if classified as such, the ordinance does not provide for the possibility of using a notice on the front label, clearly informing the consumer that the product is lactose-free or that it contains a low amount of lactose (1), with the exception of processed soy-based food that, according to RDC 91/2000 (21), must state the following information: "Contains lactose", "Contains milk proteins" or "Contains lactose and milk proteins".

This study is justified by the need to map the availability of information on the amount of lactose in processed foods, since people affected by the lactase deficiency have difficulty in choosing foods to control the symptoms and often exclude them without necessity, which may compromise their health-related quality of life, which refers to the impact of the intervention, i.e., food restriction on the perception of well-being (22), and its nutritional status. Also, failure to report the amount of lactose hampers the nutritionist's calculation of diets and nutritional orientation of lactose-intolerant patients. Thus, the aim is to evaluate the availability of information on the amount of lactose in processed food labels and by the Customer Service Department (SAC).

Methods

This is a cross-sectional and quantitative observational study evaluating the availability of information for the population of the amount of lactose in traditional processed and diet/light/zero foods marketed in a hypermarket in the city of Uberlandia, Minas Gerais. The hypermarket was intentionally selected because it has an abundant supply of processed foods and is considered the second largest supermarket company in Brazil (23) by the Brazilian Supermarket Association (ABRAS).

The evaluation was carried out in two stages. In the first, a diagnosis was made concerning the presence of information on the amount of lactose in the labels of processed foods. In the second, food industries were contacted, when this was free, over the telephone, by e-mail or through company websites to request information on the amount of lactose in their products, clarifying that this information would be used for scientific research.

Data was collected in 2015, following a written authorization by the hypermarket's management. Information included processed foods that contained milk or lactose in different positions in the list of ingredients, of different brands and flavors. Foods with the above characteristics, with the same composition, but with different packaging sizes, were excluded. It is worth noting that the position in the list of ingredients indicates, in decreasing order, the amount of the ingredient in the final product of the processed food, that is, the ingredients with higher amounts (24) appear in the first positions.

The information was collected in this study by an instrument pre-tested by the researchers, with a sample of 20 foods to define the following items: technical name; trading name; brand; telephone or e-mail of the customer service (SAC); position of lactose or milk in the list of ingredients; portion in grams and nutritional composition.

The foods were divided into two groups: traditional and diet/light/zero. In the latter, only diet foods were included, for nutrient-restricted diets or for controlled ingestion of nutrients (considered special purpose foods) (20) or with supplementary nutritional information (light, which is one with reduction of some nutrient compared to traditional and zero, which does not contain a particular nutrient) (25). Each group was subdivided into 17 and 11 categories, respectively, according to the Brazilian Food Classification System (26).

Following data collection and entry, a review of the information entered by two other researchers was carried out and descriptive statistical analysis was performed on the number and percentage of the results obtained. The comparison of the percentages of the declaration of the amount of lactose between traditional and diet/light/zero foods was performed using the chi-square test, with a significance level of 5%. The GraphPad Instat software version 3.05 was used for statistical analysis.

Results

The total sample of processed foods was 1,209, of which 1,092 (90.3%) were traditional foods and 117 (9.7%) corresponded to diet/light/zero foods. Foods properly classified and included in the analysis are described in Chart 1.

The total percentage of the declaration of the amount of lactose in the nutritional table of processed food labels was 3.1%. The declaration was more frequent (p < 0.0001) in the diet/light/ zero food group (30%) than in the traditional food group (0.2%) (Table 1). Among the products that reported the amount of lactose (n = 38), 36 (95.0%) were diet/light/zero, of which 30.6% stated that the amount of lactose was equal to zero, and the remaining 2 (5.0%) were traditional foods.

Table 2 described foods that contained the milk in the first two positions of the list of ingredients and that probably are foods with a more considerable amount of lactose. Processed foods with the highest frequency of milk/lactose in the last positions in the list of ingredients and those that did not have a significant number of foods within the same category were not shown.

Among the foods that presented lactose as the main ingredient in its formulation, the most important are the infant formulas, in which 50% contained lactose in the first position (n=8) and 19% in the second position (n = 3).

Of the 257 food industries responsible for the production of food evaluated, 156 (60.7%) provide access to the free SAC and were contacted. Among them, only 14 (9.0%) reported the amount of lactose contained in the requested foods. Ninety-three companies (59.6%) responded to the request but did not report the amounts. Of these, 61 (65.6%) replied that such information is a secret formulation and cannot be provided due to internal policy, and 32 (34.4%) reported that they could not make this information available, since they do not perform the analysis of sugars separately as the declaration on the food label is not mandatory, and 49 companies (31.4%) did not respond to the request.

Discussion

The main contribution of the study was to show the low availability of information on the amount of lactose in processed foods, either on labels or through the Customer Service Department (SAC). Only 3.0% of the processed foods analyzed showed lactose content on the nutritional table of their label, and only 9.0% of the industries contacted provided such information. Traditional foods had a lower percentage of declaration of lactose content in nutritional tables when compared to diet/light/zero foods.

It is worth mentioning that most of the diet/light/zero foods that reported the amount of lactose were foods with controlled intake of sugar, lactose-free or lactose-restricted. These data indeed show the compliance by the industries with the specific legislation, such as Ordinance No. 29/1998 (20) and RDC No. 54/2012 (25), which provide, respectively, foods with controlled intake of sugars and those with complementary nutritional information concerning sugars, which in turn, require the declaration of the amount of sugars in the nutritional information table when a Supplementary Nutrition Information is performed. However, not all diet/light/zero foods contained a declaration of the amount of lactose.

The lack of access to information on the amount of lactose in the label of processed foods violates consumers' fundamental right to information, which consequently impairs their autonomy through the nutritional orientation received and freedom of choice concerning the food consumption (16). On the other hand, it hinders the nutritionist's work in the calculation and advice on lactose controlled amounts to ensure tolerance, since some people tolerate around 11g (corresponding to 240 ml of milk per day), while others evidence intolerance symptoms (12) with the ingestion of small amounts (2 to 3 g of lactose, corresponding to a small chocolate tablet). The appearance of symptoms depends on the amount of lactose ingested, the type of food in which the lactose was consumed and the degree of lactase deficiency (27).

Lack of knowledge of the amount of lactose in food may trigger symptoms in the individual, and is a source of distress for the family (especially for mothers of children with this clinical condition)28. Therefore, this theme transcends the nutritionist professional practice core and includes a broader field, in which health professionals will have to address the physical and emotional care of the individual and the family, and promote health education, acting in a complementary way (29).

Other diseases whose fundamental part of the treatment is the total exclusion of some nutrients to avoid the emergence of symptoms and more severe health consequences, such as phenylketonuria and celiac disease, already have specific regulations for the declaration of presence on the label, which in these specific cases are for phenylalanine and gluten, respectively (30-34). However, there are still gaps in the legislation to regulate nutritional labeling for the declaration of essential nutrients for the dietary treatment of some diseases, such as galactosemia and fructose intolerance, inborn metabolism errors that imply the restriction of the substrate (galactose and fructose, respectively) for disease control (35).

Concerning lactose, Law No. 13.305 of July 4, 2016 was recently approved and mandates the declaration of the presence of lactose on the labels of food containing lactose and the remaining lactose content in foods whose original lactose content has changed (36). However, it does not require the declaration of the amount of lactose in foods that have not undergone any change, essential information for patients with lactose intolerance, since lactose must not necessarily be excluded but restricted according to tolerance.

Currently, RDC No. 26/2015 (37) was approved and establishes the requirements for mandatory labeling of the main foods that cause food allergies, including milk, and will also assist individuals with lactose intolerance in the choice of food, but will still not provide the amount of lactose for the appropriate adjustment to individual tolerance. It is worth mentioning that allergy to milk protein and lactose intolerance are different clinical situations. In the former, the individual evidences an immunological response to the presence of milk protein (caseins and whey proteins), whereas poor digestion of milk carbohydrate, namely, lactose (16), is found in lactose intolerance.

Another critical factor is that even foods that are recommended and more tolerated by patients with lactose intolerance, such as yogurts, may evidence varying amounts (2.1 to 6.4 g of lactose per 100g of yogurt) depending on their form (liquid, flavored or with pieces) (38), which can cause symptoms in those who consume them. It is worth mentioning that yogurts are recommended because they theoretically have low lactose concentration, because of their hydrolysis in the fermentation process due to the participation of microorganisms, which reduces the amount of lactose in the final product (39).

Some industrial food processing may require the addition of milk or lactose because of its influence on the viscosity, texture and role played by proteins that contribute to softness, lower humidity and higher shelf life of foods (40,41).

Besides, lactose has a low sweetening power when compared to sucrose. However, its hydrolysis is an alternative for the acquisition of a sweeter syrup containing glucose and galactose, which is a useful process to the food industry, since it allows the production of fermented products (yogurt), it facilitates its use in the formulation of foods without harming the natural flavor of other components and provides technological advantages insofar as it reduces crystallization risks in dairy products and increases sweetening power (42-44). Another useful and promising feature for the industry, especially in the case of infant formulas, is that lactose can promote the absorption of calcium and phosphorus (44).

As the food industry widely uses them due to the properties mentioned above, these foods can be consumed by people with lactose intolerance, without being aware of the presence and quantity of milk or lactose, which can lead to the appearance of symptoms, since this information is currently not stated on food labels. Thus, it is necessary to alert consumers, especially the lactose intolerant, concerning the consumption of these products.

This study filled a gap in the discussion on lactose labeling in processed foods, as no previous scientific studies were found to verify the availability of information to consumers, especially those with lactose intolerance, on the amount of food lactose.

However, it has been considered that the declaration of milk or lactose in the list of ingredients necessarily implies the presence of lactose in the final product, which is a limitation, since the processing of milk and dairy products and the animal race influence nutritional composition, and especially lactose concentration (45,46).

Conclusion

There is low availability of information on the amount of lactose in processed foods. This was evidenced in this study by the low percentage of traditional and diet/light/zero foods that directly inform the amount of lactose in food labels and the high proportion of companies that do not provide such data when required.

Thus, it becomes indispensable to standardize and supervise the nutritional labeling of lactose effectively for the general population and, in particular, for individuals with lactose intolerance. The lack of information violates consumers' right to information and can compromise the food and nutritional security of those requiring lactose intake control, as well as impairs the independent choice of food and hampers professional nutritional counseling.

DOI: 10.1590/1413-812320182312.21992016

Collaborations

RAB Batista performed the bibliographic review, data collection and analysis, interpretation of the results and drafting of the paper. DCB Assuncao participated in data collection, and critically reviewed and approved the final version of the paper. FRO Penaforte performed data statistical analysis, and critically reviewed and approved the final version of the paper. CC Japur idealized and guided the writing and development of the paper (conception, design, analysis and interpretation of data), critically reviewed the writing and approved the final version of the paper.

Acknowledgments

We are grateful to the Federal University of Uberlandia Institutional Scientific Initiation Scholarship Program (PIBIC), which together with the Minas Gerais Research Support Foundation (FAPEMIG) granted a scientific initiation scholarship, and to the management of the hypermarket, which authorized data collection within the establishment.

References

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Article submitted 04/08/2016

Approved 23/11/2016

Final version submitted 25/11/2016

Raissa Aparecida Borges Batista [1]

Dyessa Cardoso Bernardes Assuncao [1]

Fernanda Rodrigues de Oliveira Penaforte [2]

Camila Cremonezi Japur [3]

[1] Curso de Nutricao, Faculdade de Medicina, Universidade Federal de Uberlandia. Av. Para 1720/bl. 2U/sl. 12, Umuarama. 38400-902 Uberlandia MG Brasil. raissaborges26@ hotmail.com

[2] Curso de Nutricao, Instituto de Ciencias da Saude, Universidade Federal do Triangulo Mineiro. Uberaba MG Brasil.

[3] Curso de Nutricao e Metabolismo, Departamento de Ciencias da Saude, Faculdade de Medicina de Ribeirao Preto, Universidade de Sao Paulo. Ribeirao Preto SP Brasil.
Table 1. Percentage of processed foods containing the declaration of
the amount of lactose in the nutritional table of traditional and
diet/light /zero food labels.

                                                 Traditional food

Food group                       Total food      Total        Total
                                 evaluated     evaluated     declared
                                              ([section])     n (%)
                                                             ([pounds
                                                            sterling])

Milk                                 56           50         0 (0.0%)
Oils and fats                        12           10         0 (0.0%)
Edible iced products                 74           72         0 (0.0%)
Candy, confectionery, bonbons,      123           114        0 (0.0%)
chocolates and the like
Cereals and cereal or cereal-        49           41         0 (0.0%)
based products
Bakery products and biscuits        165           160        0 (0.0%)
Meat and meat products               12           12         0 (0.0%)
Sugar and honey                      8             8         0 (0.0%)
Soups and broths                     8             8         0 (0.0%)
Sauces and seasonings                10           10         0 (0.0%)
Protein products yeasts             461           396        2 (0.5%)
Beverages                            23           19         0 (0.0%)
Snacks                               13           13         0 (0.0%)
Desserts and powders for             74           65         0 (0.0%)
desserts
Processed cookery preparations       82           82         0 (0.0%)
Nutrition supplements                14            8         0 (0.0%)
Preparations to add to milk          25           24         0 (0.0%)
Total                               1209         1092        2 (0.2%)

                                    Diet/light/zero food

Food group                          Total         Total
                                  evaluated      declared
                                 ([section])      n (%)
                                                 ([pounds
                                                sterling])

Milk                                  6        3 (50.0%) *
Oils and fats                         2          0 (0.0%)
Edible iced products                  2          0 (0.0%)
Candy, confectionery, bonbons,        9        5 (56.0%) *
chocolates and the like
Cereals and cereal or cereal-         8          0 (0.0%)
based products
Bakery products and biscuits          5          0 (0.0%)
Meat and meat products                0          0 (0.0%)
Sugar and honey                       0          0 (0.0%)
Soups and broths                      0          0 (0.0%)
Sauces and seasonings                 0          0 (0.0%)
Protein products yeasts              65        18 (28.0%) *
Beverages                             4        2 (50.0%) **
Snacks                                0          0 (0.0%)
Desserts and powders for              9        8 (89.0%) *
desserts
Processed cookery preparations        0          0 (0.0%)
Nutrition supplements                 6          0 (0.0%)
Preparations to add to milk           1          0 (0.0%)
Total                                117       36 (30.0%) *

* P-value < 0.0001; ** P-value <0.05; ([section]) Total evaluated:
total number of traditional processed and diet /light /zero foods
evaluated in this study; ([pounds sterling]) Total declared: total
number of traditional processed and diet /light /zero foods declaring
the amount of lactose in the nutritional table of food labels.

Table 2. Processed foods with milk in the first or second positions.

Processed foods                  Total       Milk position in the list
                                evalued            of ingredients

                                                First         Second

                                  n         n (%) [pounds   n (%) [??]
                              ([section])     sterling]

UHT cow milk                      44          44 (100%)       0 (0%)
Powder milk                        8          8 (100%)        0 (0%)
Condensed milk                     5          5 (100%)        0 (0%)
Curds                              5          5 (100%)        0 (0%)
Yogurts                           121         120 (99%)       1 (1%)
Fermented milk                    43          42 (98%)        0 (0%)
Cheese Products                   17          15 (95%)        1 (6%)
Cheese                            131         125 (95%)       0 (0%)
Desserts                          62          56 (90%)        4 (6%)
Dairy drinks                      70          57 (81%)       12 (17%)
Dairy compounds                    5           4 (80%)       1 (20%)
Curd cheese                       38          22 (58%)       15 (39%)
Mixes for the preparation         16           8 (50%)       7 (44%)
of coffee and milk-based
beverages
Powders for the preparation       22          11 (50%)        1 (5%)
of enriched beverages
Sauces                             5           2 (40%)       1 (20%)
Infant formulas                   15           6 (40%)       2 (13%)
Powders for the preparation        4           1 (25%)       3 (75%)
of coffee and milk-based
beverages
Chocolates                        77           6 (8%)        24 (31%)

([section]) Total number of evaluated foods; ([pounds sterling]) Total
number and percentage of foods with milk in the first position against
the total evaluated foods; Total number and percentage of foods with
milk in the second position against the total evaluated foods.

Chart 1. Description of food by food category.

Food categories                        Food included

Milk                 UHT cow milk (whole, skimmed, semi-skimmed);
                     cow's milk powder (whole, skimmed, semi-
                     skimmed); goat milk (whole, skimmed, semi-
                     skimmed); and pasteurized whole cow's milk.

Oils and fats        Margarine; and butter and margarine-derived
                     foods.

Edible iced          Ice cream and powders for ice cream preparation.
products

Candy,               Confectionery (almonds, cashew nuts, chips,
confectionery,       sticks, among others); bonbons (with milk
bonbons,             chocolate, stuffed with coconut, chocolate with
chocolates and       peanuts, and others); hazelnut creams (hazelnut
the like             with cocoa, chocolate and hazelnut with wafer);
                     condensed milk; toppings; nougats; chocolates
                     (white, half bitter, aerated with milk, milk,
                     among others); and candies (caramel of milk with
                     cappuccino, caramel of milk stuffed with coconut,
                     among others).

Cereals and cereal   Cereal bars; morning cereals; milk flours and
or cereal-based      pasta.
products

Bakery products      Toast; cheese breads; cookies; breads; cakes;
and biscuits         bagels; corn-bread; mixes for the preparation of
                     bakery products; pies; cookies and crackers.

Meat and meat        Sausages; breaded chicken breast; Spanish sirloin
products             and lamb meat.

Sugar and honey      Dietetic sweeteners.

Soups and broths     Corn cream; mixes for the preparation of soups;
                     polenta and bean soup with pasta.

Sauces and           Sauces (cheese and tomato with ricotta) and pates
seasonings           (pork, turkey breast and ham).

Protein products     Dairy drinks; curds; milk creams; cheese creams;
yeasts               cheese products; cheeses; curd cheeses; yogurts;
                     infant formulas; dairy compounds and food with
                     isolated soy protein and milk.

Beverages            Liquors; mixes and powders for the preparation of
                     cappuccino or instant milk and coffee-based
                     beverages.

Snacks               Salty and sweet snacks.

Desserts and         Sweets and mixes for the preparation of desserts
powders for          such as flans, puddings, mousses, among others.
desserts

Processed cookery    Lasagna; shepherd's pies; rice; balls; chicken
preparations         dumplings; vol-au-vents; purees; sandwiches; baby
                     food; pizzas; pancakes; salted cakes;
                     stroganoffs; pies; among others.

Nutrition            Food supplements; protein bars; nutritional
supplements          supplement and powders for the preparation of
                     beverages for weight loss diet and powders for
                     the preparation of enriched drinks.

Preparations to      Powdered chocolate drink and powders for the
add to milk          preparation of beverages, for example,
                     milkshakes, among others.
COPYRIGHT 2018 Associacao Brasileira de Pos-Graduacao em Saude Coletiva - ABRASCO
No portion of this article can be reproduced without the express written permission from the copyright holder.
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Author:Batista, Raissa Aparecida Borges; Assuncao, Dyessa Cardoso Bernardes; Penaforte, Fernanda Rodrigues
Publication:Ciencia & Saude Coletiva
Date:Dec 1, 2018
Words:5562
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