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Lactose Intolerance

Dear Dr. B: I have been told I am lactose intolerant. What does that mean? How did I get the problem? What can I do about it? What is my prognosis?

Answer: Lactose is a natural sugar found in milk and dairy products. Lactose intolerance means inability to digest lactose. This inability results from a shortage of the enzyme lactase, which is normally produced by the cells that line the small intestine.

Function of lactase is to break down milk sugar into simpler forms that can then be absorbed into the bloodstream. Lactose is broken down in the intestine by lactase to glucose and galactose. These simple sugars are easily absorbed through the intestinal wall and enter the blood stream to be transported to the liver. Galactose is further broken down in the liver into glucose.

Lactose intolerance commonly develops after adolescence. It is more common in certain ethnic groups. Information obtained from the internet suggests that between 30 and 50 million Americans are lactose intolerant.

Certain ethnic and racial populations are more widely affected than others. As many as 75 percent of all African Americans and American Indians and 90 percent of Asian Americans are lactose intolerant. The condition is least common among persons of northern European descent.

Medical literature says that at birth large amount of lactase may be present in the intestine. But as the child grows the level of lactase may fall and by adolescence the level may be low enough that the milk can no longer be digested.

Lactase deficiency may be congenital. Or the deficiency may be acquired. It may occur temporarily after a bout of gastroenteritis. Certain digestive diseases and injuries to the small intestine can reduce the amount of enzymes produced. But for most people, lactase deficiency is a condition that develops naturally over time.

Absence of lactase will make lactose ferment in the intestine and cause symptoms.
Common symptoms include nausea, cramps, bloating, gas, and diarrhea. The severity of symptoms varies depending on the amount of lactose each individual can tolerate.

Most individuals will be diagnosed by the typical symptoms they experience. You may be asked to keep a diary for few days of what you eat and the symptoms you get. You may be advised to completely quit dairy products and see if the symptoms disappear. Then you will be asked to go back on the dairy products. If the symptoms reappear then the diagnosis is confirmed

The most common tests used to measure the absorption of lactose in the digestive system are the lactose tolerance test, the hydrogen breath test, and the stool acidity test.

Lactose intolerance is usually permanent in adults. The symptoms can be completely relieved by eliminating lactose from the diet by avoiding milk and milk products. Others can use lactase liquid or tablets to help digest the lactose. Other option would be to drink lactose-reduced milk available at supermarkets. This milk contains all the nutrients found in regular milk.

Milk is an important source of calcium in our diet. We need calcium for growth and repair of bones. If milk and milk products are avoided then consult your dietitian or physician to suggest other sources of calcium for your body.

Although lactose intolerance is widespread, it does not pose serious threat to our health.

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Flatulence and Bloating

Dear Dr. B: I suffer from bloating and flatulence. Why do I have so much flatulence? How can I get rid of it?

Answer: Dictionary defines flatulence as the presence of excessive gas in the digestive tract. Sometime ago I had written a column on this subject. Next day, a friend sent me the following:


A question past through the ages
And pondered by many, including the sages
Is it better to hold the fart and feel the pain?
Or let the fart and feel the shame!

To fart or not to fart is a dilemma faced by everybody on a daily basis. A survey shows that 97 per cent of Canadians suffer from intestinal gas, and about 15 per cent say they have cancelled a date or a meeting because of it.

Releasing intestinal gas is a normal and important physiological function. From birth to death, the production of intestinal gas continues unhindered.

Fart is the word easily understood by all. Quite often though, we are afraid to use the word in public, fearing the mere mention of the word “fart” would make people smell something foul! Sorry, Dr. Pavlov!

Those who have had children will never forget the countless times we have had to wait for the baby to burp or pass flatus before he or she (I mean the baby) would finish the bottle. The release of gas had dual effect – some relief for the infant and great relief for the parent.

It does not matter whether you are a king or a queen, a prince or a princess, rich or poor – we all have to release intestinal gas. Unfortunately, and quite often, the desire to release gas is not always at a socially convenient place.

For example, if the Queen has to pass gas then what does she do? What about our politicians? They blow lot of gas verbally. What do they do when they have to release intestinal gas during the Question Period in the Parliament?

President Lyndon B. Johnson (1908-1973), a Democrat, said of his Republican rival Gerald Ford, “So dumb he can’t fart and chew gum at the same time.” Of course, Gerald Ford went on to become President of the United States.

What about the astronauts? Have you ever wondered why they go out for a space walk?

What about Saddam Hussein’s dilemma in that six by eight feet “spider hole”? For eight months he was hiding in that tiny place with little ventilation and a small fan. Once a very powerful man now stuck in a hole smelling his own body odor and release of intestinal gas. Did he have any gas masks with him?

A textbook of Gastroenterology says that gas and bloating embrace three unrelated phenomena. Farting is a physiologic phenomenon due to the production of gas by colonic bacteria. Excessive belching or burping is associated with aerophagia (air swallowing). And the mechanism of bloating is obscure.

Usually, intestinal gas consists of odorless gas – carbon dioxide and hydrogen – produced by bacterial action on carbohydrates and the proteins in the food we eat. There is methane and swallowed nitrogen as well. These four gases make up 99 percent of colonic gas.

The remaining component consists of trace gases that compensate for their small quantities by their strong odors. Smelly gases include hydrogen sulfide, ammonia, indole and volatile fatty acids.

The textbook says that an average person on normal diet emits about one liter of gas per day. On an average we pass gas 13.6 times per day – although there is great variation from person to person, from time to time, what you eat, and how much air you swallow.

You can reduce gas by eliminating certain foods (peas, beans, cauliflower, certain grain products, carbohydrates etc.) in your diet. Patients with irritable bowel syndrome and lactose intolerance may have excess gas.

There is only one way to get rid of gas – look over your shoulder and let it go!

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What you should know about vasectomy?

Dear Dr. B: My husband and I have two beautiful children. We have decided that my husband should get a vasectomy. What should we know about vasectomy?

Answer: Vasectomy is a type of contraception – a surgical method of male sterilization. Contraception allows us to choose the number of children we want. There are many ways to do this. Most methods are designed for women. For men there are only two methods of contraception: condom or vasectomy.

More than 220 million couples worldwide use sterilization as their contraceptive method of choice. In western countries, about 20 – 25 percent of couples of reproductive age choose vasectomy as their method of contraception. Approximately 500,000 vasectomies are performed in the United States annually.

In my own practice the number of vasectomies done each year has gone up. For example, in the year 2003, I did 194 no-scalpel vasectomies compared to year 2000 when I did 117. In the last seven years, I have done 896 vasectomies.

Vasectomy is a permanent and irreversible procedure. Reversal procedures are being done but the success rate varies a lot. Therefore, it is important that you exercise this option carefully. You should undertake pre-operative counseling and consultation with your family physician and the surgeon doing the procedure.

Vasectomy is an office procedure. It is done under local anesthetic. Except for some discomfort for few seconds associated with infiltration of local anesthetic, the procedure itself is painless. But most patients are anxious. In my practice, I prescribe pre-operative sedation which helps calm the nerves.

The procedure is usually bloodless. It is done through a very tiny opening in the middle of the scrotum with a special instrument (not a scalpel) and no stitches are required.

Are there any post-operative complications?

Studies have shown that no-scalpel method has fewer complications than the conventional method.

Swelling and pain due to bleeding or infection is a possibility. The incidence can be anywhere from one to 10 percent. Mostly it is minor. About five percent of patients may have some chronic discomfort in the scrotal area. The nature of this can vary a lot.

Can vasectomy fail? Failure rate for tubal ligation is 18 per 1000 procedures. For vasectomy, the failure rate is one per 500 to 1000 procedures. In the last 13 years, I have had two documented vasectomy failures. One was in 1991 and second one in 1993.

Vasectomy does not immediately render the patient sterile. The sacs that hold semen contain sperms after vasectomy has been done. Other methods of contraception should be used until semen analyses (after two and three months) show that no sperms are left. Unfortunately, 30 percent of patients do not go for sperm analyses. That is not good.

Sperm granuloma, the cause of some pain after vasectomy, is caused by leakage of sperm from the vas. It develops in about 15-40 percent of men after surgery and may cause pain in three percent.

Vasectomy does not adversely affect a man’s sexual function. Current evidence does not show that vasectomy causes prostate or testicular cancer or would adversely affect a man’s health in any way.

Post-operatively, patients are advised to use ice-packs and to take it easy for couple of days. Exertion should be avoided for a week. If there are no complications then no pain killers are required.

So, vasectomy is a safe and effective method of long-term contraception. Remember, it is permanent and irreversible. Reversal procedures are being done but the success rate can be low. On the other hand, it is also important to remember that vasectomy can fail and there is no guarantee of permanent sterility.

Update (May 3, 2007): I have recorded a short video about this procedure on my video blog which can be viewed here.

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Best Exercise

Dear Dr. B: Many people are confused about the type and amount of exercise necessary to become fit. Is there anything like “the best exercise”?

Answer: The type and amount of exercise required to become fit and healthy depends on your age, your health and your current state of physical fitness.

There are three types of exercises: aerobic, weight lifting (resistance training) and stretching.

Aerobic exercise involves continuous activity. It increases endurance and helps body use oxygen more effectively. It makes the lungs, heart and muscles strong. It is good for cardiovascular fitness.

Examples of aerobic exercises are: swimming, brisk walking, running, bicycling, climbing stairs, cross country skiing, using stationary bike etc.

However, flexibility, strength and muscular endurance also form an important part of any physical fitness program. Aerobic exercise should be combined with weight lifting and stretching. This helps improve muscle strength and flexibility. These exercises also help endurance and balance. A good exercise program should benefit all three aspects of fitness:

-Stamina
-Flexibility
-Strength

Review of literature suggests that swimming is excellent for all three aspects of fitness. It probably fits the definition of a perfect or best exercise. When swimming, you can burn 12 calories per minute. Compare this to jogging 9.6 km. (six miles) an hour, cross-country skiing, squash and handball where you can burn 10 to 11 calories per minute.

To build stamina, the best exercises are: swimming, basketball, bicycling, climbing stairs, dancing, hiking, and jogging.

To build flexibility, the best exercises are: swimming, basketball, dancing, tennis and yoga.

To build strength, the best exercises are: swimming, bicycling, and climbing stairs.

Except for swimming, none of the other exercises cater to all three aspects of fitness. Therefore, you should combine more than one type of activity in your schedule to maximize your fitness.

To prevent boredom and monotony, you should change the exercise regime and goals every six to eight weeks. This keeps your mind and body working towards a new goal. A professional qualified trainer can help you achieve this.

Some exercises burn more calories than others. This is important for people who are trying to lose weight.

You can lose two calories per minute by just standing or sitting at one place. You can lose up to four calories a minute by walking 3.2 km (two miles) an hour or bicycling eight km. (five miles) an hour.

You can lose up to seven calories a minute by indulging in sexual activity, shoveling dirt, skating or bicycling 16 km. (10 miles) and hour. Anyway, who would like to shovel dirt when you can burn calories by getting involved in a romantic activity?

Other examples are: housework burns five calories/minute; raking leaves burns six calories/minute; tennis, shoveling snow, downhill skiing, and water-skiing burn eight calories/minute; and basketball burns eight to 10 calories/minute.

What about golf? Golf is not a good activity to build stamina. It is good for flexibility. And has small effect on building strength. You can lose 250 calories per hour when you golf riding a cart.

A study done by Golf Digest showed that a golfer who walks 18 holes while carrying his bag travels an average of 9.4 km. (5.9 miles) and burns 1811 calories. A rider with no cart path restrictions, surprisingly, walks an average of 3.7 km. (2.3 miles) and burns 859 calories.

Thirty minutes a day of exercise can do wonders for you. Exercising in three 10-minute sessions is comparable to a workout in 30 minutes all at once.

To retain muscle mass and strength, you should do resistance training for 20 minutes three times a week. According to Newsweek, Harvard runners study has shown that men who trained with weights for 30 minutes or more per week cut their risk of heart disease by 23 percent.

So, swimming is the best exercise. But there are many other activities to choose from. Whatever you do, make sure you are having fun!

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!