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Volume27,Issue2
January2008
Pages93103

Reviewarticle:lactoseintoleranceinclinicalpracticemythsandrealities
M.C.E.LOMER, G.C.PARKES, J.D.SANDERSON

Firstpublished:
23October2007 Fullpublicationhistory

DOI:
10.1111/j.13652036.2007.03557.x View/savecitation

Citedby:
153articles Citationtools

DrM.C.E.Lomer,DepartmentofGastroenterology,GuysandStThomasNHSFoundationTrust,London
SE17EH,UK.
Email:miranda.lomer@kcl.ac.uk

Summary
BackgroundApproximately70%oftheworldpopulationhashypolactasia,whichoftenremains
undiagnosedandhasthepotentialtocausesomemorbidity.However,noteveryonehaslactose
intolerance,asseveralnutritionalandgeneticfactorsinfluencetolerance.
AimsToreviewcurrentclinicalpracticeandidentifypublishedliteratureonthemanagementoflactose
intolerance.
MethodsPubMedwassearchedusingthetermslactose,lactaseanddiettofindoriginalresearch
andreviews.Relevantarticlesandclinicalexperienceprovidedthebasisforthisreview.
ResultsLactoseisfoundonlyinmammalianmilkandishydrolysedbylactaseinthesmallintestine.
Thelactasegenehasrecentlybeenidentified.Wildtypeischaracterizedbylactasenonpersistence,
oftenleadingtolactoseintolerance.Twogeneticpolymorphismsresponsibleforpersistencehavebeen
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identified,withtheirdistributionconcentratedinnorthEuropeans.Symptomsoflactoseintolerance
GoTo
includeabdominalpain,bloating,flatulenceanddiarrhoea.Diagnosisismostcommonlybythelactose
hydrogenbreathtest.However,mostpeoplewithhypolactasia,ifgivenappropriateadvice,cantolerate
somelactosecontainingfoodswithoutsymptoms.
ConclusionInclinicalpractice,somepeoplewithlactoseintolerancecanconsumemilkanddairy
foodswithoutdevelopingsymptoms,whereasotherswillneedlactoserestriction.

Introduction
Lactoseintoleranceiswidespreadthroughouttheworldandsubjectsusuallyavoidmilkanddairyproducts
toimprovesymptoms.Thedisaccharidelactoseisauniquecarbohydratepresentonlyinmammalianmilk,
7.2g/100mLinmaturehumanmilk,4.7g/100mLincowsmilkbutisnegligibleinthemilkofsomemarine
mammals. 1 Foreffectiveutilization,lactoserequireshydrolysisbytheenzymelactaseand,duringinfancy,
providesanexcellentsourceofenergyatatimeofrapidgrowthanddevelopment.Anenhanced
understandingoflactaseanditsdeficiencyandwhythereisaspecialcarbohydrateinmilkisimportantfor
improvedmanagementoflactoseintolerance.

Pathophysiology
Theenzymelactasephlorizinhydrolase,morecommonlyknownaslactase,isagalactosidase
responsibleforthehydrolysisoflactosetothemonosaccharides,glucoseandgalactose.Theseare
absorbedbyintestinalenterocytesintothebloodstream(Figure1),glucoseisultimatelyutilizedasa
sourceofenergyandgalactosebecomesacomponentofglycolipidsandglycoproteins.Theenzymehas
twoactivesites,onehydrolysinglactoseandtheotherphlorizin(anarylglucoside)andarangeof
dietaryglycolipids. 2 Anumberofactionsofthephlorizinsiteareusefulinhumansandthisexplainswhy
someenzymeactivityisretainedfollowingtheusualdeclineinenzymeexpressionafterweaningfrom
breastmilk(seebelow).

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Figure1. GoTo
Openinfigureviewer

Inlactasepersistence,lactasephlorizinhydrolaseinthebrushborderefficientlyhydrolyses
lactoseintogalactose(Gal)andglucose(Glu)andisrapidlyabsorbedintothebloodstream
takingluminalwaterwithit.Hydrolysistypicallyoccursinthejejunum,whichhaslow
concentrationsofbacteria10 14 mL 1 thus,littlelactoseisfermented.

Lactaseispresentontheapicalsurfaceofenterocytesinthesmallintestinalbrushborderwiththehighest
expressioninthemidjejunum.ItissecuredbyitsCterminalendwithmostofthemoleculeprotrudinginto
thegastrointestinallumen.Theenzymeisproducedasa220kDaprecursorpeptide,whichundergoes
considerableposttranscriptionalmodificationduringtransporttothecellsurfaceasthemature150kDa
protein.Luminalfactorsalsocontributetofinalmodificationoftheproteintoproducetheactiveenzymeby
cleavageoftwofurtheraminoacidsbypancreatictrypsin. 3
Byweek8ofgestation,lactaseactivitycanbedetectedatthemucosalsurfaceinthehumanintestine.
Activityincreasesuntilweek34andbybirth,lactaseexpressionisatitspeak.However,withinthefirstfew
monthsoflife,lactaseactivitystartstodecrease(lactasenonpersistence).Inmostmammals,itdeclinesat
variableratesfollowingweaningtoundetectablelevelsasaconsequenceofthenormalmaturational
downregulationoflactaseactivity. 46 Inhumans,approximately30%ofthepopulationhascontinued
lactaseactivitybeyondweaningandintoadulthood(lactasepersistence). 7 Thishappensmainlyinpeople
ofnorthEuropeandescentandrelatesgeographicallytotheintroductionofdairyfarmingapproximately
10000yearsago. 8 RecentanalysisofarchaeologicalDNAsuggeststhatgeneticlactasepersistencewas
rareinNorthernEuropeanspriortodairyfarming.Thesocalledculturehistoricalhypothesisproposes
thatthehighprevalenceoflactasepersistenceinNorthernEuropeansoccurredasaresultofamore
recentselectionprocessenablingpopulationstorelyonmammalianmilkasanimportantcomponentof
thedietparticularlyattimeofpoorharvest. 911 Anopposinghypothesisreversecauseproposedthat
dairyfarmingandmilkconsumptionwasadoptedbythosewithpreexistinglactasepersistence 10,12,13 but
evidencefromarchaeologicalDNAsuggeststhatthisislesslikely. 14
Hypolactasia,orlactasedeficiency,existsinthreedistinctforms:congenital,primaryandsecondary.
Congenitallactasedeficiencyisassociatedwiththeleastlactaseactivity.Itisalifelongdisorder
characterizedbyfailuretothriveandinfantilediarrhoeafromthefirstexposuretobreastmilk.Congenital
lactasedeficiencyisextremelyrare,withonlyaround40caseshavingbeenreported.Itisasingle
autosomalrecessivedisorder,butverylittleisknownaboutthemolecularbasis. 15 Theonlytreatmentis
completeavoidanceoflactosefrombirth.Lactasenonpersistence(primarylactasedeficiency),as
describedabove,occursinthemajorityofhumans.Secondaryoracquiredlactasedeficiencyreferstothe
lossoflactaseactivityinpeoplewithlactasepersistence.Itoccursasaresultofgastrointestinalillnessthat
damagesthebrushborderofthesmallintestine,e.g.viralgastroenteritis,giardiasisorcoeliacdisease. 16,
17
Thisisusuallyreversible.
Foreffectiveutilizationoflactosewithoutsymptomsofintolerance,only50%oflactaseactivityis
necessary 15 anditispresentonlyatthelevelthatitisrequired,asisthecaseforotherintestinal
disaccharides. 18
Formanyyears,itwasthoughtthatlactasepersistenceinhumanswasthewildtypepattern. 19 Asthe
lactasenonpersistencephenotypeisexpressedinothermammals,thisisnowconsideredtobethe
ancestraltypewhilstlactasepersistenceisbecauseofamutation.

Geneticsoflactaseexpression

20 21,22
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Thelactasegeneisapproximately50kbinsize 20 andlocatedonchromosome2. 21,22 Wildtypeis

GoTo
characterizedbylactasenonpersistencewhilsttwosinglenucleotidepolymorphisms(SNPs)inthelactase
genehavebeenassociatedwithlactasepersistence.TheseareC/T 13910 andG/A 22018 substitutions
occurring14and22kbupstreamofthe5endofthelactasegeneinaDNAregion,whichfunctionsasa
cis actingelementinfluencingthelactasegenepromoter. 15,21,23 StudiessuggestthatC/T 13910 isthe
dominantpolymorphismwiththe C allelelinkedtoadeclineinlactasemRNAexpression.However,the
exactmechanismofthisdeclineafterweaningisuncertain. 24
IndividualsheterozygousforeitherSNPhaveintermediatelactaseactivityandaremoresusceptibleto
lactoseintoleranceattimesofstressorgastrointestinalinfection. 5 Thispolymorphismdoesnotprovidea
completeexplanationasindividualswithhomozygouslactasepersistence(genotypesTTandAA)may
occasionallydeveloplactoseintolerance(i.e.acquiredlactasedeficiency. 25 Adulthomozygoteswith
nonpersistence(CCandGG)havevirtuallyundetectablelevelsofintestinallactaseasaresultofdown
regulationofthebrushborderenzymefollowingweaning. 26

Prevalenceoflactoseintolerance
Hippocratesfirstdescribedlactoseintolerancearound400years.buttheclinicalsymptomshave
becomerecognizedonlyinthelast50years. 5 Upto70%oftheworldpopulationhaslactase
nonpersistence, 5 butnotallareintoleranttolactoseasmanynutritionalandgeneticfactorsinfluence
tolerance. 8,27
Ethnicoriginaffectsthefrequencyoflactoseintolerance.Inadults,whitenorthEuropeans,North
AmericansandAustralasianshavethelowestratesrangingfrom5%inaBritishpopulationto17%in
FinlandandnorthernFrance.InSouthAmerica,AfricaandAsia,over50%ofthepopulationhaslactase
nonpersistenceandinsomeAsiancountriesthisrateisalmost100%. 1,4,15,23,2836 Interestingly,in
subjectsfrommixedethnicity,alowerprevalenceoflactasenonpersistenceisobservedwhereahigh
prevalenceisdetectedinthenativeethnicgroup. 30
Thedeclineinlactaseexpressionisusuallycompleteduringchildhoodbutthedeclinehasalsobeen
reportedtooccurlaterinadolescence. 33 Therateoflossoflactaseactivityalsovariesaccordingto
ethnicitybutthephysiologicalexplanationforthisdifferenceintimingiscurrentlyunknown.Chineseand
Japaneselose8090%oflactaseactivitywithin34yearsafterweaning,JewsandAsianslose6070%
overseveralyearspostweaningandinwhiteNorthernEuropeansitmaytakeupto1820yearsfor
lactaseactivitytoreachitslowestexpression. 5

Diagnosisoflactosemaldigestion
Earlystudiesoflactosedigestioninvolvedmeasuringbloodglucoselevelsfollowingalactoseloadof50g,
asignificantincreaseinbloodglucoseafter30minindicatinghighlactaseactivity. 15,25 Inresearch,serum
measurementsof 13 Clabelledlactosefollowinganoraldosehavealsobeenused,butarenotappropriate
foruseinclinicalpractice. 37
Morerecently,lactaseactivityfromjejunalbiopsieshasbeenusedbutislesssensitivethanthelactose
hydrogenbreathtest,whichiscurrentlyconsideredtobethemostcosteffective,noninvasiveandreliable
testtomeasurelactosemaldigestion. 38 Thelactosehydrogenbreathtestusuallyinvolvestaking50g
lactoseorally(equivalenttothatfoundin1Lofmilk)andmeasuringbreathhydrogenlevelsoverthe
following36hwith>20p.p.m.abovebaselineindicatinglactoseintolerance.Thesensitivityincreases
from40%to60%,ifmeasurementsaretakenfor6h. 5
Hydrogennonexcretion(afalsenegativelactosehydrogenbreathtest)occursinupto20%ofpatients
withlactosemalabsorption. 39 Thisisbecauseofapredominantpopulationofmethaneproducingbacteria
inthebowelthatusehydrogentoreducecarbondioxidetomethane 40 ormayoccurasaresultofprior
39
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antibiotics. 39 Often,thereisinterferenceandcompetitionbetweendifferentstrainsofbacteriawithinthe
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gastrointestinaltractleadingtosignificanthydrogenexcretionaswellasmoderatemethaneproduction. 40
Insomesubjects,thereisapositivelactosehydrogenbreathresultwithoutthesubjectshavinghadany
priorsymptomsoflactoseintolerance.Thisindicatesthatthesesubjectshavelactosemalabsorption,but
nosymptomspresumablybecauseofpersonaldietaryrestriction. 25
Genotyping,usinganewrealtimePCRassay,isquickandeasyandhashighspecificityforthelactase
gene. 25 Itmayhelptodifferentiatepatientswithprimaryhypolactasiafromthosewithlactoseintolerance
causedbysecondaryhypolactasia.However,thistestisnotyetroutinelyavailableinclinicalpractice.

Symptomsoflactoseintolerance
Lactosemaldigestionoccurswhenlactoseisnotabsorbedinthesmallintestine.Itpassesthroughthe
gastrointestinaltracttothecolon,where,insomesubjects,itthenleadstosymptomsoflactose
intolerance.
Thetypicalsymptomsoflactoseintoleranceincludeabdominalpain,bloating,flatus,diarrhoea,
borborygmi, 5,6,25 andonsomeoccasions,nauseaandvomiting. 5 Inafewcases,gastrointestinalmotility
isdecreasedandsubjectscanpresentwithconstipationpossiblyasaconsequenceofmethane
production.Animalmodelshaveshownamarkedreductioninthemajormigratorycomplexesofthegut
wheninfusedwithmethane,slowingguttransit. 41
Abdominalpainandbloatingaretypicallycausedbycolonicfermentationofunabsorbedlactosebythe
bacterialmicrofloraleadingtotheproductionofshortchainfattyacids(SCFA),hydrogen,methaneand
carbondioxide,thusincreasingguttransittimeandintracolonicpressure(Figure2). 42 Acidificationofthe
coloniccontentsandanincreasedosmoticloadresultingfromtheunabsorbedlactoseintheileumand
colonleadtoagreatersecretionofelectrolytesandfluidandarapidtransittimeresultinginloosestools
anddiarrhoea. 4347

Figure2.

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Openinfigureviewer
GoTo

Inlactasenonpersistence,thereareseveralpossiblemechanismsforthecommonsymptoms
foundinpatients.First,unabsorbedlactosepassingthroughthecolonhasahighosmoticload
leadingtoincreasedwaterandelectrolytesinluminalcontents,speedingtransitandsoftening
stool.Secondly,unabsorbedlactoseishydrolysedtogalactose(Gal)andglucose(Glu)by
bacterialgalactosidasepresentinlacticacidbacteria.Thesemonosaccharidesarethen
availableforbacterialfermentationbyilealandcolonicfloratoshortchainfattyacidswithby
productsofhydrogenandcarbondioxide,causingbloatinginthesmallbowelandflatulencein
thecolon.Thirdly,reductionincarbondioxidebycertainbacterialstrainstomethanecould,
theoretically,leadtoconstipationthroughareductioninsmallintestinalmajormigratory
complexes.

Careshouldbetakenwhensubjectsdescribesystemicsymptomsaswhilstthesemaybecoincidental,
theycouldbeanindicationofcowsmilkproteinallergy, 48 whichaffectsasmanyas20%ofpatientswith
symptomssuggestiveoflactoseintolerance. 5,49 CowsmilkproteinallergyisrareinadultsTrueloveand
Wrightshowedthatafewulcerativecolitispatientsbenefitedfromexclusionofdairyproductsbutthiswork
hasneverbeenrepeated. 50 Asidefrombloodydiarrhoea,extraintestinalsymptomsoccurandmay
includemuscleandjointpain,headaches,dizziness,lethargy,difficultywithshorttermmemory,mouth
ulcers,allergies(eczema,pruritis,rhinitis,sinusitisandasthma)cardiacarrhythmia,sorethroat,increased
frequencyofmicturition, 5,5153 acneanddepression. 25
Somepatientsdonotassociatetheirsymptomsoflactoseintolerancewithfoods 38 andinonestudy,52%
ofpatientsdidnotrelatetheirsymptomswiththeintakeoflactose. 54 Inaddition,substantialamountsof
lactosegiventopatientswithprovenlactasenonpersistenceandahistoryoflactoseintolerancewhowere
properlyblinded,didnotcausesignificantsymptoms. 55 Furthermore,insymptomaticpatients,excluding
lactosedoesnotalwayseliminatesymptoms 56,57 probablybecausethereisanotherunderlyingcause,
e.g.irritablebowelsyndrome(IBS).

Intestinalmicroflora,fermentationandfermentedfoods
Thereisnoevidenceforadaptationofsmallintestinalbrushborderlactaseactivityinsubjectswithlactase
nonpersistenceafteritsnaturaldecline. 4,15,30 Thegastrointestinaltracthousesatleast17bacterial
familieswithover500specieshavingbeenclassified 58 withthehighestconcentrationbeinginthecolonat
levelsupto10 1214 mL 1 luminalcontents. 59 Ithasbeendemonstratedthatmalabsorbedlactoseis
salvagedbythedistalilealandcoloniclacticacidbacteria. 60 LacticacidbacteriaareGrampositive,e.g.
Lactobacillus,Bifidobacterium,Staphylococcus,Enterococcus,Streptococcus,Leuconostoc and
Pediococcus andfermentlactosetoproducelactate,hydrogen,methane,carbondioxideandSCFAs. 61
Intheprocessoffermentation,microbiallactasepresentinlacticacidbacteria 15,62,63 initiallybreaksdown
unabsorbedlactosebyhydrolysistoitscomponentmonosaccharides,glucoseandgalactose,whichare
thenabsorbedorfermentedasabove.LactaseactivityisoptimalatpH68,asinthesmallintestine.Inthe
colon,however,wherethepHdropstoaslowas4, 64 bacteriallactaseactivityisdecreasedandlactoseis
morelikelytobeleftunfermented.Inthiscase,symptomsoflactoseintolerancearethereforemore
becauseoftheincreasedosmoticload.Thevariableabilityofthecolonicmicrofloratofermentlactosein
subjectswithintolerancemayexplainwhydifferentsubjectshavedifferentlevelsoftolerance. 65
Prebioticsaredefinedasnondigestible(bythehost)foodingredientsthathaveabeneficialeffectthrough
theirselectivemetabolismintheintestinaltract. 66 Unhydrolysedlactosecanbeconsideredtobea
prebioticandithasbeendemonstratedthatnumbersoflacticacidbacteriaincreasefollowinglactose
ingestion. 67 Fermentationofmilkimprovestolerancetolactosebecauseofthepresenceoflacticacid
61
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bacteria. 61 Thus,dairyfoodsintheformofcheeseandfermentedmilk,e.g.yogurtareestablished
GoTo
componentsofthehumandietandprovidegoodsourcesofproteinandcalciumandoftendonotleadto
symptomsoflactoseintoleranceaspartofahealthybalanceddiet.
Probiotics,definedaslivemicroorganismsthatwhengiveninadequatequantitieswillhaveahealth
benefitonthehost, 68 havebeenknowntobeinthedietsincetheearly20thcenturybutitisonlyrecently
thatinteresthasgrownintheirhealthbenefits.Insubjectswithlactoseintolerance,probioticsreduce
bloatingsymptomspossiblyasaconsequenceofmicrobiallactasebeingpresentwithinlacticacidbacteria
intheprobioticsthusimprovinglactosedigestion. 28,6974 Thereis,however,ahugevariabilityinthe
amountoflactaseactivityindifferentprobiotics(fermentedmilks0.190.24mol/gandyogurt
0.86mol/g) 75 butthisdoesnotmeanthatthefermentedproductislesswelltoleratedinlactose
intolerance. 69,71,76

Lactoseintoleranceandirritablebowelsyndrome
Irritablebowelsyndromeaffects912%ofthepopulationandpatientspresentwithatleastoneofthe
followingsymptoms:abdominalpain,bloating,constipationand/ordiarrhoea. 14,77 Dietmayinfluencethese
symptoms,inparticularmealpatterns,caffeine,theamountandtypeofnonstarchpolysaccharides
(dietaryfibre),fluidintake,gutfloraandfoodintolerance. 78 LactoseintolerancedoesnotleadtoIBS 28,79
butpatientsoftenhaveincreasedvisceralsensitivitytotheluminaleffectsoflactosecomparedtohealthy
subjects. 80 LactoseintoleranceandIBSsymptomsareoftenverysimilarandwhenrelatedtomilkintake,
theydonotnecessarilyindicatelactoseintolerance. 79,81 Intwostudies,lactosemaldigestionaffected24
27%ofpatientswithIBS. 82,83 Alpersreportedthat45%ofIBSpatientshavelactoseintolerancebutonly
30%relatedtheirsymptomstomilkanddairyproductswhiledietaryexclusiononlyimprovedsymptomsin
52%ofpatients. 84 Interestingly,someIBSpatientswithoutlactosemaldigestiondescribesymptomsof
lactoseintolerance.Furthermore,studieshaveshownthatlactosefreemilkcausesthesamesymptoms
aslactoseinsubjectswhohavebeendiagnosedwithlactoseintolerancethismayindicatethatthe
underlyingconditionisIBS. 81,85 Specificquestionsrelatedtolactoseinducedsymptomsmayimprovethe
managementofsuchpatients. 79

Lactoseinfoodandpharmaceuticals
Lactoseoccursnaturallyinthedietonlyasmammalianmilkanddairyproducts,e.g.cow,goat,sheep
(alsoknownasewe)andhuman.Levelsvaryconsiderablyfromonlyatraceinbutterto52.9g/100gin
skimmedmilkpowder,althoughwhendilutedwithwaterthisequatesto<5g/100mL(Table1). 86 Lactose
iswidelyusedinthefoodandpharmaceuticalindustryasaningredientinprocessedfoodsorasabulking
agentorfillerinpharmaceuticalsandthisfactneedstobetakenintoconsiderationwhenreducinglactose
intake.Itisonlyhalfassweetasglucoseandhasaboutasixthofthesweetnessofsucrosemakingitvery
palatable.Itisnoteasilyfermentedbyyeastandconsequentlydoesnotleadtotheunwantedproduction
ofcarbondioxideandalcoholwhenusedasaningredientinfoodproducts.Inrecentyears,therehas
beenadramaticincreaseinthemanufactureoflactoseand,intheUnitedStatesalone,productionhas
increasedfrom50millionkg/annumin1979to300millionkg/annumin2004. 5
Table1.Lactosecontentofmilk,dairyproductsandsomemanufacturedproducts 86

Food Type Percentbyweight

Milk Skimmed* 4.8

Semiskimmed* 4.7

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Food Type Percentbyweight GoTo

Whole* 4.6

Condensed,whole,sweetened* 12.3

Driedskimmed* 52.9

Evaporated,whole* 8.5

Goat 4.4

Human 7.2

Sheep 5.1

Cream Single 2.2

Double 1.7

Sour 2.7

Crmefraiche 2.1

Crmefraichehalffat 3.0

Imitationcream,e.g.Elmlea,TipTop,DreamTopping 2.36.8

Cheese Brie/camembert Trace

Cheddar 0.1

Cheesespread 4.4

Cheesespread,reducedfat 7.3

Cottagecheese 3.1

Cottagecheese,reducedfat 3.3

Creamcheese Trace

Danishblue Trace

Stilton 0.1

Edam/gouda Trace

Feta 1.4

Goatscheese 0.9

Mozzarella Trace

Parmesan 0.9

Processedcheeseslices 5.0

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Food Type Percentbyweight GoTo

Yogurt Plain 4.7

Fruit 4.0

Drinkingyogurt 4.0

Fromagefraisplain 4.0

Fromagefraisfruit 3.0

Tzatziki 0.3

Puddings Milkshakeaverage 4.5

Icecreamnondairyvanilla 4.8

Icecreamdairyvanilla 5.2

Chocice 4.7

Ricepudding 3.9

Custardmadewithwholemilk 5.2

Chocolatemousse 3.8

*Cowsmilk.

Infoods,lactosemaybeusedasabrowningagent,e.g.inbread,ortoaddtextureandbindwater,e.g.in
processedmeatssuchassausagesandburgers. 6 Itmayalsobeaddedtoprocessedchickenandcanbe
usedintheproductionofsoftdrinksandlagerbeers.Somefoodscancontainasmuchlactoseasmilk
itself,e.g.slimmingproducts. 87

Lactoseintake,restriction,reintroductionand
nutritionaladequacy
TherearecurrentlynoUKnationalguidelinesonhowtomanagelactoseintolerance.Individualswith
lactasenonpersistencedonotinevitablyacquirelactoseintolerance,especiallyiftheyconsumelactose
containingfoodsinmodestamountsatanyonetime,e.g.milkaddedtobreakfastcereal,teaorcoffee. 88
However,iflactoseintoleranceexistsordiagnosticinvestigationsareinconclusive,adetaileddietand
symptomhistoryshouldbetakenand,ifappropriate,lactosecanbeexcludedfromthediet(Table2)until
symptomsresolve,usuallyatleast4weeks.Dieteticadviceshouldbesoughttoensurenutritional
adequacyofthediet.Lactoseintoleranceshouldbeconfirmedwithalactosechallengeandthe
developmentofsymptoms. 38
Table2.Foodingredientstoavoidonalactoseexclusiondiet

Milk Lactoglobulin

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Milksolids Buttermilk
GoTo
Lactose Artificialcream

Wheypowder Feta

Caseinate* Quark

Condensedmilk Curd

Skimmedmilkpowder Ricotta

Cream Cheese

Modifiedmilk Margarine

Evaporatedmilk Butter

*Caseinateisamilkproteinanddoesnotcontainlactosebutduringtheinitialstagesofalactoseexclusiondiet,oftenall
milkanddairyingredientsareavoided.

Subjectsshouldbeencouragedtoreintroducelactosetotolerancetoensurethedietisnotbeing
restrictedunnecessarily. 79 Thesefoodsprovideanexcellentsourceofbioavailablecalciumandavoidance
leadstoalowercalciumintake, 89 whichisassociatedwithreducedbonemineraldensityandanincreased
riskofdevelopingosteoporosis. 90,91 Calciumsupplementationmayberequiredandtherecommendation
ofcalciumfortifiedfoodsshouldbeconsidered.ThecurrentrecommendationsforcalciumintakeintheUK
are700mg/dayformenandwomenover19yearsand1250mg/dayduringbreastfeeding. 92 Interestingly,
despitelactoseintolerance,calciumfrommilkanddairyproductsisstillwellabsorbed. 93,94
Afteraperiodoflactoseexclusionandcessationofsymptoms,upto240mLmilk(12glactose)isoften
welltoleratedifspreadthroughouttheday. 55 Furthermore,reintroductionoflactosecanhelpdecrease
symptomsoflactoseintolerance 95 suggestingthattheremaybeadaptationinthecolonicmicroflora
wherebythelactoseisbehavingasaprebioticasmentionedabove. 8,27 Thisisusefulinasocietywhere
theadditionoflactoseinfoodproductsisincreasing.
Thereissomeevidencethatlactaseaddedtoproductstorenderthemlowinlactoseortheuseof
supplementallactasecanhelptolerancebutthisisnotalwaysthecase. 96,97 Therehasevenbeena
suspectedcasereportofanallergytosupplementallactasealthoughthiswasbecauseofanallergytothe
fungus Aspergillus thatwasusedtomanufacturelactase. 98
Foodtemperature, 99 thepresenceofcerealsandothersolids, 100 energycontentandnutritional
compositionofameal 28,88,101,102 canaltergastricemptyingandchangeproximalintestinaltransittimeby
severalhours.Alongerexposuretimeoflactoseinthesmallintestineallowsincreasedhydrolysisby
lactaseandhelpstoreducesymptomsoflactoseintoleranceinsomesubjects. 103

Conclusions
Milkanddairyproductsareoftenassumedtobethecauseofgastrointestinalsymptomsandinappropriate
avoidancecanleadtonutritionalinadequacy,particularlyforcalciumintake.Manysubjectswithlactose
intolerancecanconsumemilkanddairyproductswithoutgettingsymptomsandfermentedmilkproducts
maybehelpfulinimprovingtolerance.Otherindividualsdobenefitsignificantlyfromlactoserestrictionbut
careneedstobetakentoensurethatcalciumintakeissufficient.Agreaterunderstandingofthe

http://onlinelibrary.wiley.com/doi/10.1111/j.13652036.2007.03557.x/full 10/11
15/3/2017 Reviewarticle:lactoseintoleranceinclinicalpracticemythsandrealitiesLOMER2007AlimentaryPharmacology&TherapeuticsWileyOn

complexityoflactoseintolerance,lactasedeficiencyandsymptomgenerationwouldhelpclinicianstreat
GoTo
patientsmoreeffectively(seeTable3).
Table3.Commonmythsandpracticaltips

Adultswithlactosenonpersistencecannottolerateanymilkordairyproducts
Peoplewithlactasenonpersistencearenotalllactoseintolerant.Theymaytolerateupto12glactoseiftakenspread
throughouttheday,e.g.withbreakfastcerealandinteaorcoffee
Lactasenonpersistenceisrare
Untilrecentlyitwasbelievedthatlactasepersistencewasthedominanttrait,however,upto70%oftheworldpopulation
islactasenonpersistent
Goatsmilkislactosefree
Goatsmilkcontains4%lactose.Soyamilkandricemilkarelactosefree.Recommendcalciumsupplementedproducts
Anegativelactosebreathtestmeansthatthepatientcantoleratealldairyproducts
Alactosebreathtestdoesnotalwaysconfirmlactoseintoleranceandhydrogennonexcretionoccursinupto20%of
patients

Acknowledgements
Declarationofpersonalinterests :None. Declarationoffundinginterests :Thewritingofthispaperwas
fundedinpartbyTheDairyCouncil,London,UK.

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