New Directions in Lactose Intolerance: Moving from Science to Solutions

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1 New Directions in Lactose Intolerance: Moving from Science to Solutions PAPANDREOU DIMITRIOS, PhD, MS., RD. Ass. Professor of Nutrition, University of Nicosia

2 A Barrier to Dairy Consumption Lactose intolerance is the No 1 barrier to health professional recommendations for dairy 80% of dietitians and doctors agree that lactose intolerance is a major reason of avoidance of milk and milk products GFK Custom Research North America, 2009

3 Exploratory Findings Dietitians LI secondary issue Many doctors LI easily solved Consumers want health professionals to knowledge their concern Ali Consumer Qualitative Research, 2008

4 Key Objectives Understand the different terminology involved in lactose intolerance Discuss the real prevalence of lactose intolerance Understand how to diagnose a person with lactose intolerance Outline the appropriate dietary strategies use to manage people with lactose intolerance Review the benefits of key dairy products

5 Inability to digest significant amounts of lactose, a sugar found in milk, accompanied by diarrhea, flatulence, bloating, abdominal discomfort Lactose is a disaccharide (galactose + glucose) Dosage very important Other factors? Modern Nutrition, 2004 Lactose Intolerance

6 Intestinal absorption requires that lactose lactase hydrolysis monosaccharide glucose + galactose

7 Prevalence of Lactose Intolerance Eastern Asia >90% Native Americans 80-95% African Americans 65-75% Hispanics Americans 50% Europe and USA 7-20% (Caucasian the lowest) National Dairy Council, 2012

8 Lactose Intake during Life Age is very important Infant 35-55% of daily calories - Intake falls as weaning foods are introduced Adults intake is about 15gr per day assuming a diet of 300gr CHO (5% lactose)

9 Terminology of Lactose Intolerance Lactase nonpersisters (LN) (lactase insufficiency) - Low activity of lactase in brush border - Requires biopsy Lactose malabsorption (LM) indicates that a small fraction of lactose is not absorbed delivered directly to colon - Requires measurement of H2 breath or blood glucose concentration after loading lactose

10 Continue Lactose intolerance (LI) indicates that lactose malabsorption produces symptoms such as: - Bloating, flatulence, diarrhea, abdominal pain Depending on quantity of lactose - 12 gr of lactose no symptoms - 25 gr of lactose few symptoms if taking together with other food - 50 gr of lactose most people would have symptoms regarding food intake Prevalence of LN and LM is far away from the prevalence of LI in people consuming modest lactose levels

11 Lactose Malabsorption Congenital Primary Secondary

12 Congenital LM Congenital lactase deficiency - Finish population 1/60,000 newborns - Rare autosomal recessive disorder-40 cases - Mutation in LCT gene Breast and bottle milk contains significant amounts of lactose - If not given lactose free formula diarrhea, dehydration, hypercalcemia, nephrocalcinosis

13 Primary LM Developmental lactase deficiency - lactase levels due to prematurity weeks (premature infants) reduced lactase activity

14 Primary LM Adult-type hypolactasia Most common form of LM It is genetically determined Developed at 5 years of age and decline gradually C/T Most prominent in USA, Sweeden

Frequencies of the LCT-13910 C T Allele Country Allele frequency % U.S.

15 Frequencies of the LCT C T Allele Country Allele frequency % U.S.A (Utah) 74,5 Sweden 73,7 Netherlands 69 Austria 53 Hungary 36 India 19,5 Brazil 25 Italy (North-East) 24 Italy (Central) 13 Greece 9 Sardinia 7 China 0 Japanese 0 Clinical and Experimental Gastr., 2012

16 Secondary LM Bacterial Overgrowth Increased fermentation of lactose Mucosal injury of GIT Celiac disease Crohn s disease IBS AIDS Satta et al. 2012

17 Clinical Symptoms Abdominal pain Bloating Flatulence Diarrhea Vomiting Bulky watery stools

18 Meal content effects on symptoms Meals with gastric emptying symptoms Meals with gastric emptying symptoms

19 Diagnosis Most accurate method biochemical assay from jejunal sample Replaced by endoscopic duodenal biopsy, sensitivity 95%, specificity 100%

20 Diagnosis Lactose tolerance test - Oral administration of 50gr lactose - Blood glucose levels 0,60,120 - BG by <20mg/dl and symptoms = LM - Diabetes, bacterial overgrowth false results - Sensitivity 75%, specificity 96% - Problems? 25 gr (New) Harrington and Mayberry, 2008

21 Lactose breath hydrogen test Diagnosis Oral administration of 25 g baseline and every 30 min for 4h Hydrogen values 20 ppm diagnostic ppm inderminate (requires symptoms) 10ppm normal Recent smoking, antibiotics use, lung disorders may give false results Sensitivity 60% Harrington and Mayberry, 2008

22 Diagnosis Children acidity stool test - Usually reflects bacterial overgrowth or - abnormal intestinal mucosa and production of lactic acid Harrington and Mayberry, 2008

23 Health Outcomes of Dairy Exclusion Low Ca ++ intake <RDI Osteoporosis, bone fractures, diabetes, CVD, Hypertension, Cancer Vitamin and mineral deficiencies National Medical Association 2010

24 Recommended Ca ++ Dietary Intake Age 0-6 m 7-12 m 1-3 y 4-8 y 9-18 y y 51 y Amount of Ca ++ in mg ,300 1,000 1,200 Dietary References Intake, 2004 National Academy of Science

100gr 325mg Spinach frozen 1 cup 291mg Salmon canned w/bone 100gr 181mg

25 Ca ++ in Foods Product Amount Ca ++ content Milk 1 cup 285mg Yogurt 1 cup 415mg Swish cheese 30gr 224mg Ice cream ½ cup 84mg Sardines w/bone 100gr 325mg Spinach frozen 1 cup 291mg Salmon canned w/bone 100gr 181mg Orange 1 medium 52mg Soy milk 1 cup 61mg U.S Department of Agriculture, 2008

26 Lactose Content of Dairy Products Product Lactose (g) Milk (1 cup) 12-13g Yogurt (1 cup) 5-19g Ice cream (1/2 cup) 2-6g American cheese (1oz) 1g Mozzarella 0.1g Swiss cheese 0.1g Cottage cheese 3g Lactaid milk 0g USDA, 2010

27 Key nutrients of 240 ml of milk Calcium Vitamin D Riboflavin Phosphorus Protein Vitamin B12 Potassium Vitamin A 30% DV 25% DV 24% DV 20% DV 16% DV 13 % DV 11% DV 10% DV National Medical Association 2010

28 Treatment of LI We need to keep in mind that: LI is not a disease and can be easily managed Not able to improve the body s ability to produce lactase Symptoms can be controlled through dietary strategies

29 Factors affecting lactose tolerable levels Dose and timing of lactose Co-injection with other foods Fluid held in gut (100 ml vs 120 by unabsorbed 12 gr of lactose Gases from bacterial fermentation Individual differences-idiosyncrasy Gastric emptying Sensitivity of colon -IBD

30 Strategies to Address LI Hydrolyzed milk, lactase supplements Prebiotics and probiotics Incremental lactose for colonic adaptation Key result: Insufficient evidence U.S Department of Health, 2010

31 What LI individuals should know LI is not a disease Milk is the leading food source of Ca ++, vitamin D, potassium and magnesium Dairy avoidance increases the risk of osteoporosis, bone fractures, vitamins and mineral deficiencies There are strategies to allow consumption of dairy foods with minimal or no symptoms

32 Continue Consumers / Patients and Physicians / Dietitians Get informed - Consumers / patients and physicians / dietitians must understand how to minimize LI symptoms - View dairy foods with a positive way (investment in health) - Become educated by dietary Guidelines National Medical Association 2010

33 Continue Physicians / Dietitians Include questions about LI when taking a medical history Encourage pts/consumers to be tested for LI or provide guidance on gradual introduction of dairy into diet National Medical Association

34 Continue Physicians / Dietitians Identify those at risk Educate them National Medical Association 2010

35 Strategies to Address LI Consumers / Patients dairy products gradually (2-4 oz/d) Yogurt choice? Cheeses (cheddar, mozzarella)? Elimination of milk is not necessary-lactose free milk Mixed dairy products with other food

There are varying degrees of sensitivity to lactose The prevalence of LI is unclear There is insufficient evidence about enzyme replacement, dietary supplements and

36 There are varying degrees of sensitivity to lactose The prevalence of LI is unclear There is insufficient evidence about enzyme replacement, dietary supplements and probiotics A g of lactose in a single dose provides no symptoms thus there is no need to avoid dairy Summary Gradually increase lactose in the diet Lactose intolerance or lactose

37 Thank you for your attention

Lactose Intolerance National Digestive Diseases Information Clearinghouse

Lactose Intolerance National Digestive Diseases Information Clearinghouse National Institute of Diabetes and Digestive and Kidney Diseases NATIONAL INSTITUTES OF HEALTH What is lactose intolerance? Lactose