Cow’s milk free diet for adults

Cow’s milk allergy occurs when the body’s immune system reacts to proteins found in milk. Allergic reactions can be immediate (within minutes to 2 hours) or delayed (between 2-72 hours).

Immediate symptoms may include a combination of the following:

• itchy skin rashes (redness or hives)
• swelling of the face, eyes or lips
• runny nose, itchy eyes
• eczema
• coughing
• vomiting
• swallowing or breathing difficulties (rare)

Delayed symptoms may include a combination of the following:

• diarrhoea
• constipation
• acid reflux
• profuse vomiting
• abdominal pain, bloating or distension
• mucous and/or blood in the stools
• nausea
• painful wind, excess gas
• eczema

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In this resource:

• Lactose intolerance
• Diagnosis
• Management
• Calcium and vitamin D requirements
• Medicines
• Checking food labels
• Suitable foods and foods to avoid
• Eating out
• Travel Tips
• Recipes
• Useful websites
• Suggested meal pattern

Lactose intolerance

Lactose intolerance is often confused with milk protein allergy but it is NOT an allergy.

Symptoms of lactose intolerance

• diarrhoea and/or constipation
• abdominal bloating or distension
• nausea
• wind, excess gas
• abdominal pain

It occurs when the body cannot digest lactose, a type of sugar in milk. The most common form of lactose intolerance is called “secondary lactose intolerance”. This can occur after a bout of gastroenteritis (stomach bug) or as a result of an inflamed gut, such as in Coeliac Disease. Secondary lactose intolerance is temporary and resolves when the gut heals. In very rare cases, babies are born with a lactose intolerance that is not temporary. It is usually identified at birth and requires strict lifelong avoidance of lactose. Some people develop lactose intolerance later in childhood or adulthood but can often tolerate small amounts of lactose.

Lactose intolerance is treated by following a low lactose diet. Most people with lactose intolerance can manage to eat some low lactose foods (e.g. hard cheese, butter and yogurt) and even small amounts of cow’s milk without causing symptoms. It is important to discuss with your Dietitian which milk containing foods you can tolerate.

Diagnosis

It is important that food allergies are properly diagnosed by a healthcare professional with the relevant training. They will ask detailed questions about symptoms, the history of any reactions and may perform tests. The type of tests advised will depend on how the patient has reacted.

Immediate onset allergic reactions are known as IgE mediated allergy. Skin prick tests or blood tests which measure IgE antibodies may be used to help with the diagnosis. The results of these tests are often difficult to interpret, which is why it is essential that they are carried out and read by a qualified allergy specialist. Sometimes, a food challenge may be needed before a definite diagnosis can be made. This is when increasing amounts of the suspected food are given and symptoms monitored. This is usually done under supervision in the hospital setting and should not be done at home unless you have been advised it is safe to do so by an allergy specialist.

Delayed onset allergic reactions are known as non-IgE mediated allergy. There are no reliable skin or blood tests that can provide a diagnosis for this type of allergy. The only reliable way to make a diagnosis is to exclude the suspected food(s) from the diet for a trial period of 2-4 weeks to see if the symptoms improve. The food(s) are then reintroduced to see if the symptoms return. Your Dietitian will give you further advice on how to do this.

Patch testing is not recommended to diagnose food allergy as reliability has been shown to be low. It is therefore not recommended by any official body as a test for delayed onset of food allergy. However, patch testing may be used by specialists to diagnose contact allergies not related to food e.g. allergy to cosmetics.

Some companies offer allergy or food intolerance tests that measure IgG antibodies. These have not been found to be a reliable way to diagnose delayed or immediate reactions. Other tests such as hair analysis, kinesiology testing and vega testing have also been found to be unreliable and have no scientific basis, and therefore should not be used.

Management

Cow’s milk allergy should in most cases be treated with a strict cow’s milk free diet. Your Dietitian will help you to avoid milk while making sure that you get the nutrition you need. You should discuss with your Dietitian or Doctor how strict your diet needs to be.

This diet is free of both cow’s milk proteins (casein and whey) and lactose (milk sugar). Goat’s and sheep’s milk and milk from all other animals should also be avoided as they contain similar allergenic proteins to cow’s milk. The following sections will help you to follow a milk free diet.

Calcium and vitamin D requirements

By using replacement foods such as calcium enriched alternative yogurts, desserts and milks you can still ensure that you get enough calcium so that bones stay strong and healthy. Calcium requirements vary according to age and gender:

Vitamin D is needed by the body to absorb calcium. You should take a supplement containing 10mcg/400IU vitamin D throughout the winter and also during the summer if you:

• have very little or no sun exposure
• are pregnant or breastfeeding
• are over 65 years
• are housebound for long periods
• cover your skin for cultural reasons
• have darker skin.

Good sources of calcium

Spinach, dried fruits, beans, seeds and nuts are not good sources of calcium. This is because they contain oxalates and/or phytates which reduce how much calcium your body can absorb from them. You should not rely on them as your main sources of calcium.

Medicines

Many medications and nutritional supplements contain lactose. If this is medical grade lactose, the cow’s milk protein content will be minimal. Therefore, most people will not need to avoid products containing medical grade lactose. Contact your pharmacist and Dietitian if you think you have reacted to a certain medicine.

Iodine

Milk is a good source of iodine which is needed to make thyroid hormones and also for the development of a baby’s brain during pregnancy and early life. As milk is a good source of iodine, it is important that a milk- free diet contains other iodine rich foods such as fish. If you are unable to eat fish, your Dietitian can advise on other suitable iodine containing foods or supplements if required. The following table shows how much is needed for each age group, according to the World Health Organisation (WHO):

Further information on foods containing iodine can be found here.

Checking food labels

Food allergen labelling law requires that common food allergens used as ingredients or processing aids must be declared on the packaging or at the point of sale. The list of 14 common food allergens includes milk.

These laws apply to all packaged and manufactured foods and drinks sold. They also apply to foods sold loose (e.g. from a bakery, delicatessen, butcher or café) and foods packed or pre-packed for direct sale (e.g. café, sandwich bar, food outlet, market stall, some catering products). If you travel outside Europe , be aware that labelling laws are different so check ingredients carefully.

For pre-packed products (e.g. made in a factory) and food prepacked for direct sale (such as in a café, sandwich shop, deli or food outlet preparing food in their own kitchen) allergens must be listed in one place on the product label (i.e. in the ingredients list) and highlighted (e.g. in bold or underlined).

Example of food label containing cow’s milk:

More information on food allergy labelling is available from NHS Choices.

There are different rules for:

• foods sold without packaging such as in a bakery, café or pub. For these foods, allergen information has to be provided either in writing or verbally. If provided verbally, the business must be able to provide further written information if requested (in the UK only).

There are many ways in which milk can be labelled, so carefully check the ingredients list on food items. By law you must be able to clearly tell that a product contains milk e.g. if casein is listed, it should tell you in brackets that this is ‘from milk’. Avoid foods which contain:

Milk ingredients:

• Buttermilk
• Cow’s milk (fresh, UHT)
• Condensed Milk
• Cream/artificial cream
• Evaporated milk
• Butter, butter oil
• Ghee
• Margarine
• Cheese
• Fromage Frais
• Ice Cream
• Yogurt
• Casein (curds), caseinates
• Calcium or sodium caseinate
• Hydrolysed casein
• Hydrolysed whey protein
• Lactoglobulin
• Lactoalbumin
• Lactose*
• Milk powder, skimmed milk powder
• Milk protein
• Milk sugar
• Milk solids, nonfat milk solids
• Modified milk
• Whey, whey solids, hydrolysed whey
• Whey protein, whey syrup sweetener

*Lactose - Please discuss with your Dietitian to what extent you will need to avoid lactose.

Milk free foods may also be referred to as being ‘dairy free’.

Always check the label: manufacturers change their ingredients from time to time e.g. ‘new improved recipe’. It is always safer to recheck the ingredients list.

May contain…’ or ’Made in a factory…’ labelling statements

These warnings are used by food manufacturers to highlight a possible risk of an otherwise milk free product being accidentally contaminated by milk during manufacturing, including on vegan products. There is currently no law to say how or when this type of labelling should be used but it appears on a wide variety of products. The way these statements are worded does not indicate their level of importance, e.g, ‘not suitable for….’ does not mean there is a greater risk of contamination than ‘made in a factory….’. Tolerance to foods with a ‘may contain’ labelling does not always mean that trace amounts of allergen are tolerated.

It is important to discuss your approach to these foods with your Dietitian or Doctor. It is recommended that your child:

Allergy Alerts

Sometimes foods have to be withdrawn or recalled. There may be a risk to customers because the allergy labelling is missing, wrong or if there is any other food allergy risk. You can get these alerts from the Food Standards Agency website. It is also possible to subscribe to a free email or SMS text message alert system to receive messages when Allergy Alerts are issued. To subscribe, go to: www.food.gov.uk/news-alerts/subscribe

Alternatively, you can view product alerts online from: www.anaphylaxis.org.uk/information-training/allergy-alerts/

Cross contamination

Cross contamination can occur whilst preparing foods. If traces of milk need to be avoided, ensure that all work surfaces and chopping boards are well cleaned or use separate chopping boards. Use separate containers for jams, butter etc and use clean utensils for serving them. High risk situations where cross contamination can occur include: barbeques, buffets, deli-counters and self- service salad bars. Pre-packed sandwiches are also a risk for cross contamination and are best avoided.

Suitable foods and foods to avoid

The following pages give examples of cow’s milk free foods and foods which may contain cow’s milk. Please note this is not an exhaustive list - always check labels and discuss with your Dietitian about how to approach ‘May Contain’ labelling.

*Please note that foods listed were milk free at the time of publishing.

Please continue to check labels as product content may change.

Current Law states that if a business provides food to their customers directly, for example in a restaurant or cafe, they must provide allergen information in writing. This could be either:

• full allergen information on a menu, chalkboard or in an information pack
• a written notice placed in a clearly visible position explaining how their customers can obtain this information - for example by speaking to a member of staff. Further information here.

Distance selling

If food is sold through distance selling, for example through a telephone or online order for a takeaway, allergen information must be provided at two stages in the process:

• before the purchase of the food is completed - this could be in writing (for example on a website, catalogue or menu) or orally (for example by phone)
• when the food is delivered - this could be in writing (for example on allergen stickers on food or enclosed hard copy of menu) or orally (for example by phone)

The allergen information should be available to a customer in a written form at some point between a customer placing the order and taking delivery of it.

If you are ordering through a food delivery company e.g. Deliveroo, Just Eat, Uber Eats, you must contact the restaurant directly to inform them of your allergies and to find out whether the meal is suitable. You should do this every time you make a new order.

Tips for eating out

Depending on your reactions, particularly if they are quite severe, you may find some of these tips useful:

• Carry your rescue medication with you and make sure it is in date.
• Check out the restaurant’s website – many contain nutritional and allergy information.
• Ring the restaurant in advance to ensure they can cater for your allergy. Try to call at off-peak times when the staff will have more time to deal with your query.
• Get to know the chef in your favourite local restaurant.
• Speak to your waiter/waitress or the chef on arrival to check they are all aware of your food allergy.
• You may find it helpful to use a ‘chef card’ such as those available to buy from www.dietarycard.co.uk or print off from here. Hand the card to your waiter/waitress and this will help to ensure that correct information is passed to the chef and if necessary that the food you have requested should not have any contact with or products that contain milk.
• Keep to “simple” foods on the menu. Sauces and gravies contain many ingredients which cannot always be remembered by staff.
• If you do not understand the description of a menu item, it is safer not to order it.
• Avoiding the busiest times may be helpful in ensuring staff are attentive and have time to check ingredients.
• Remember milk may not be mentioned in the description of a dish – check for hidden sources e.g. in marinades.
• Self-service areas, buffets and salad bars are also at risk of cross contamination from one dish to another.
• Make sure those you are dining with know about your allergies and know what to do if you have a reaction and are unwell.
• If in doubt, choose to eat elsewhere.
• If eating with friends or at a party, remember to tell the host about your milk allergy in advance so they can prepare suitable dishes.
• Some restaurants have signed up to the Allergy UK ‘Allergy Aware’ scheme This shows that staff have had allergy training and the restaurant follow recommended procedures to ensure safety for customers with food allergies.

Travel tips

Depending on your reactions, particularly if they are quite severe, you may find some of these tips useful.

• Carry your rescue medication in your hand luggage e.g. antihistamines, adrenaline auto- injector and action plan with you and make sure they are in date.
• If you are travelling abroad, check in advance how to describe your allergies in the local language. There are several websites that provide useful phrases and eating out translation cards in a variety of languages.
• If you are flying, speak to your airline well in advance to check if they can meet your dietary needs. Make yourself known to the flight crew to ensure the correct meal is received and ask for an ingredient list of the meals provided.
• Consider taking suitable snacks for the journey in case your flight is delayed or your meal is not available on the day of travel.
• Try to obtain a letter from your Doctor or Dietitian explaining why you need to take special food items.
• Any special food items not needed for the flight should be put in your suitcase. Be careful with fruit, vegetables or meat as these are often not allowed to be brought into a country.
• Some airlines require a letter from the Doctor/Dietitian allowing you to take more than a 100ml of liquid, antihistamine, hypoallergenic formula etc.
• If you are taking an adrenaline auto-injector, obtain a letter from your Doctor that confirms your allergy.
• Make sure the friends you are travelling with know about your allergies and what to do if a reaction occurs.
• If you are staying in a hotel, try to get a room with a kitchen area in case there are no safe places to eat out.
• Ensure you have the telephone number of the local hospital or emergency services and keep your medical insurance number handy in case you need it.
• You can check local restaurants and menus through Trip Advisor and other similar sites. You may find useful tips and also contact details of restaurants to contact them prior to you going.
• Ensure your child always carries some sort of allergy ID. Medical ID bracelets, ID cards and travel containers to protect medicines from excessive heat or cold are available from: www.medicalert.org.uk, and www.sostalisman.com,
• Consider adding Medical ID’ details to your smartphone. This information is accessible from the lock screen and in case of emergency, enables quick access to information about your allergies, other important medical information and emergency contacts.

Recipes

Many items that usually contain cows’ milk protein can be adapted by using a milk substitute and milk free margarine.

Helpful Hints

• Use calcium fortified alternative milks (e.g. soya, rice, oat, nut, coconut) to make sauces, pancakes, batter and desserts.
• Allow hot drinks to cool a little before adding soya milk as it may curdle.
• Grate soya hard cheeses on the fine part of the grater if they are not melting very well.
• Use plain milk free yogurts or coconut milk to make curries, raita, stroganoffs, creamy sauces and dips.
• You can use egg white replacer to make a milk free whipping cream or use Soyatoo™ whipping cream (spraycan).
• Use a milk free melting cheese (e.g. Cheezly melting mozzarrella™ or Mozzarisella™) on pizza, cheese on toast and on lasagne.
• Use a hard milk free cheese (Sheese™) to make cheese sauces. Grate on the fine part of the grater so that it melts more easily. Using a microwave will save it sticking to the bottom of the saucepan (which also works for milk free custard & porridge).
• Use milk free cream cheese/sour cream or milk free plain yogurt in dips, cheesecakes, quiches and savoury and sweet sauces.

Useful websites

Useful recipe websites

• www.allrecipes.com
• www.bbcgoodfood.com/recipes
• www.foodsmatter.com/freefrom_recipes/index.html
• www.allrecipes.com
• www.kidswithfoodallergies.org
• www.yummly.com

Patient support

Online shopping

Suggested meal pattern

Breakfast

Bread, cereals and other starchy foods.

Milk and dairy alternatives.

Meat, fish, eggs, beans and other non-dairy sources of protein.

Fruit.

Drink.

Mid morning snack

Lunch

Meat, fish, eggs, beans and other non-dairy sources of protein.

Bread, rice, potatoes, pasta and other starchy foods.

Vegetables.

Fruit.

Dairy food alternatives.

Drink.

Mid afternoon snack

Evening

Meat, fish, eggs, beans and other non-dairy sources of protein.

Bread, rice, potatoes, pasta and other starchy foods.

Vegetables.

Fruit.

Dairy food alternatives.

Drink.

Supper

Bread, cereals and other starchy foods.

Milk and dairy free alternatives.

Fruit.

Drink.