Lactose Intolerance

Posted on 15 Dec 2009 14:38




What is lactose intolerance?

Lactose intolerance is the inability or insufficient ability to digest lactose, a sugar found in milk and milk products. Lactose intolerance is caused by a deficiency of the enzyme lactase, which is produced by the cells lining the small intestine. Lactase breaks down lactose into two simpler forms of sugar called glucose and galactose, which are then absorbed into the bloodstream.

Not all people with lactase deficiency have digestive symptoms, but those who do may have lactose intolerance. Most people with lactose intolerance can tolerate some amount of lactose in their diet. Up to 250 ML of milk can be tolerated by most adult lactose intolerants.

Most adult mammals, including humans, only retain a fraction of the intestinal lactase activity of infants who need the enzyme to digest mother's milk. Therefore, it should be understood that lactose sensitivity or intolerance is the normal state of most human groups. Europeans are a peculiar exception to this rule and lactose persistence in Europe is the subject of much research.

People sometimes confuse lactose intolerance with cow milk allergy. Milk allergy is a reaction by the body’s immune system to one or more milk proteins and can be life threatening when just a small amount of milk or milk product is consumed. Milk allergy most commonly appears in the first year of life, while lactose intolerance occurs more often in adulthood.

What causes lactose intolerance?

The cause of lactose intolerance is best explained by describing how a person develops lactase deficiency.

Primary lactase deficiency develops over time and begins after about age 2 when the body begins to produce less lactase. Most children who have lactase deficiency do not experience symptoms of lactose intolerance until late adolescence or adulthood.

Drawing of the digestive tract. The stomach, liver, large intestine, small intestine, appendix, and anus are labeled.

The digestive tract.


Researchers have identified a possible genetic link to primary lactase deficiency. Some people inherit a gene from their parents that makes it likely they will develop primary lactase deficiency. This discovery may be useful in developing future genetic tests to identify people at risk for lactose intolerance.

Secondary lactase deficiency results from injury to the small intestine that occurs with severe diarrheal illness, celiac disease, Crohn’s disease, or chemotherapy. This type of lactase deficiency can occur at any age but is more common in infancy.

Who is at risk for lactose intolerance?

Lactose intolerance is a common condition that is more likely to occur in adulthood, with a higher incidence in older adults. Some ethnic and racial populations are more affected than others, including African Americans, Hispanic Americans, American Indians, and Asian Americans. The condition is least common among Americans of northern European descent (see Lactase Persistence in Europe for origins and explanation).

Infants born prematurely are more likely to have lactase deficiency because an infant’s lactase levels do not increase until the third trimester of pregnancy.

What are the symptoms of lactose intolerance?

People with lactose intolerance may feel uncomfortable 30 minutes to 2 hours after consuming milk and milk products. Symptoms range from mild to severe, based on the amount of lactose consumed and the amount a person can tolerate.

Common symptoms include

* abdominal pain
* abdominal bloating
* gas
* diarrhea
* nausea

How is lactose intolerance diagnosed?

Lactose intolerance can be hard to diagnose based on symptoms alone. People may think they suffer from lactose intolerance because they have digestive symptoms; however, other conditions such as irritable bowel syndrome can cause similar symptoms. After taking a medical history and performing a physical examination, the doctor may first recommend eliminating all milk and milk products from the person’s diet for a short time to see if the symptoms resolve. Tests may be necessary to provide more information.

Two tests are commonly used to measure the digestion of lactose.

Hydrogen Breath Test. The person drinks a lactose-loaded beverage and then the breath is analyzed at regular intervals to measure the amount of hydrogen. Normally, very little hydrogen is detectable in the breath, but undigested lactose produces high levels of hydrogen. Smoking and some foods and medications may affect the accuracy of the results. People should check with their doctor about foods and medications that may interfere with test results.

Stool Acidity Test. The stool acidity test is used for infants and young children to measure the amount of acid in the stool. Undigested lactose creates lactic acid and other fatty acids that can be detected in a stool sample. Glucose may also be present in the stool as a result of undigested lactose.

Because lactose intolerance is uncommon in infants and children younger than 2, a health professional should take special care in determining the cause of a child’s digestive symptoms.

So many milk products

How is lactose intolerance managed?

Although the body’s ability to produce lactase cannot be changed, the symptoms of lactose intolerance can be managed with dietary changes. Most people with lactose intolerance can tolerate some amount of lactose in their diet. Gradually introducing small amounts of milk or milk products may help some people adapt to them with fewer symptoms. Often, people can better tolerate milk or milk products by taking them with meals.

The amount of change needed in the diet depends on how much lactose a person can consume without symptoms. For example, one person may have severe symptoms after drinking a small glass of milk, while another can drink a large glass without symptoms. Others can easily consume yogurt and hard cheeses such as cheddar and Swiss but not milk or other milk products.

The Dietary Guidelines for Americans 2005 recommend that people with lactose intolerance choose milk products with lower levels of lactose than regular milk, such as yogurt and hard cheese.

Lactose-free and lactose-reduced milk and milk products, available at most supermarkets, are identical to regular milk except that the lactase enzyme has been added. Lactose-free milk remains fresh for about the same length of time or longer than regular milk if it is ultra-pasteurized. Lactose-free milk may have a slightly sweeter taste than regular milk. Soy milk and other products may be recommended by a health professional.

People who still experience symptoms after dietary changes can take over-the-counter lactase enzyme drops or tablets. Taking the tablets or a few drops of the liquid enzyme when consuming milk or milk products may make these foods more tolerable for people with lactose intolerance.

Parents and caregivers of a child with lactose intolerance should follow the nutrition plan recommended by the child’s doctor or dietitian.

Lactose Intolerance and Calcium Intake

Milk and milk products are a major source of calcium and other nutrients. Calcium is essential for the growth and repair of bones at all ages. A shortage of calcium intake in children and adults may lead to fragile bones that can easily fracture later in life, a condition called osteoporosis.

The amount of calcium a person needs to maintain good health varies by age. Recommendations are shown in Table 1.

Table 1. Recommended calcium intake by age group
Age group Amount of calcium to consume daily, Age group in milligrams (mg)
0–6 months 210 mg
7–12 months 270 mg
1–3 years 500 mg
4–8 years 800 mg
9–18 years 1,300 mg
19–50 years 1,000 mg
51–70+ years 1,200 mg

Source: Adapted from Dietary Reference Intakes, 2004, Institute of Medicine, National Academy of Sciences.


Women who are pregnant or breastfeeding need between 1,000 and 1,300 mg of calcium daily.

Getting enough calcium is important for people with lactose intolerance when the intake of milk and milk products is limited. Many foods can provide calcium and other nutrients the body needs. Non-milk products that are high in calcium include fish with soft bones such as salmon and sardines and dark green vegetables such as spinach.

Table 2 lists foods that are good sources of dietary calcium.

Table 2. Calcium content in common foods
Non-milk Products Calcium Content
Rhubarb, frozen, cooked, 1 cup 348 mg
Sardines, with bone, 3 oz. 325 mg
Spinach, frozen, cooked, 1 cup 291 mg
Salmon, canned, with bone, 3 oz. 181 mg
Soy milk, unfortified, 1 cup 61 mg
Orange, 1 medium 52 mg
Broccoli, raw, 1 cup 41 mg
Pinto beans, cooked, 1/2 cup 40 mg
Lettuce greens, 1 cup 20 mg
Tuna, white, canned, 3 oz. 12 mg
Milk and Milk Products Calcium Content
Yogurt, with active and live cultures, plain, low-fat, vitamin D-fortified, 1 cup 415 mg
Milk, reduced fat, vitamin D-fortified, 1 cup 285 mg
Swiss cheese, 1 oz. 224 mg
Cottage cheese, 1/2 cup 87 mg
Ice cream, 1/2 cup 84 mg

Source: Adapted from U.S. Department of Agriculture, Agricultural Research Service. 2008. USDA National Nutrient Database for Standard Reference, Release 21.


Yogurt made with active and live bacterial cultures is a good source of calcium for many people with lactose intolerance. When this type of yogurt enters the intestine, the bacterial cultures convert lactose to lactic acid, so the yogurt may be well-tolerated due to a lower lactose content than yogurt without live cultures. Frozen yogurt does not contain bacterial cultures, so it may not be well-tolerated.

Calcium is absorbed and used in the body only when enough vitamin D is present. Some people with lactose intolerance may not be getting enough vitamin D. Vitamin D comes from food sources such as eggs, liver, and vitamin D-fortified milk and yogurt. Regular exposure to sunlight also helps the body naturally absorb vitamin D. Talking with a doctor or registered dietitian may be helpful in planning a balanced diet that provides an adequate amount of nutrients—including calcium and vitamin D—and minimizes discomfort. A health professional can determine whether calcium and other dietary supplements are needed.

What other products contain lactose?

Milk and milk products are often added to processed foods—foods that have been altered to prolong their shelf life. People with lactose intolerance should be aware of the many food products that may contain even small amounts of lactose, such as

* bread and other baked goods
* waffles, pancakes, biscuits, cookies, and mixes to make them
* processed breakfast foods such as doughnuts, frozen waffles and pancakes, toaster pastries, and sweet rolls
* processed breakfast cereals
* instant potatoes, soups, and breakfast drinks
* potato chips, corn chips, and other processed snacks
* processed meats, such as bacon, sausage, hot dogs, and lunch meats
* margarine
* salad dressings
* liquid and powdered milk-based meal replacements
* protein powders and bars
* candies
* non-dairy liquid and powdered coffee creamers
* non-dairy whipped toppings

Checking the ingredients on food labels is helpful in finding possible sources of lactose in food products. If any of the following words are listed on a food label, the product contains lactose:

* milk
* lactose
* whey
* curds
* milk by-products
* dry milk solids
* non-fat dry milk powder

Lactose is also used in some prescription medicines, including birth control pills, and over-the-counter medicines like products to treat stomach acid and gas. These medicines most often cause symptoms in people with severe lactose intolerance.

Lactose Intolerance is NOT the Same as Milk (Protein) Allergy

A intolerance is not the same as an allergy. Many people with lactose intolerance are confused by the differences between their problems with milk products and milk allergies but it is important to realize that the two are not related at all. And while a lactose intolerance from mild to severe discomfort, a milk allergy can cause a life-threatening response.

What is a Milk Allergy?

A milk allergy, like any allergy is an abnormal immune response to milk. Specifically it is a sensitivity to one or more of the proteins found in milk and is one of the most common allergies in children.

The two major proteins in milk are whey and casein. Casein is the protein that forms a curd when milk is left to turn sour and whey is the watery part that is left after the curd is removed. A person can be allergic to either one of these proteins.

Whey protein is the most common and clincially significant allergen. It contains other protein fractions, the two most abundant of which are alpha-lactalbumin and beta-lactaglobulin. Reactions to these produce IgE-antibodies (Immunoglobulin E) and these antibodies can be tested for to determine if a person has an allergy.

The symptoms of a milk allergy are much more wide-ranging and serious than those of a simple lactose intolerance. And they may occur at different times after consumption: sometimes immediately; sometimes several hours later; and sometimes even several days later. Immediate reactions are associated with the most severe symptoms and my include:

  • vomiting
  • diarrhea
  • skin rash
  • hives
  • gastroesaphageal reflux
  • anaphylaxis (severe)

Lactose on Food Labels

"Lactose-free" or "lactose-reduced" milk and other products are widely available in grocery stores. These products may be fortified to provide the same nutrients as their lactose-containing counterparts.

There is no FDA definition for the terms "lactose free" or "lactose-reduced," but manufacturers must provide on their food labels information that is truthful and not misleading. This means a lactose-free product should not contain any lactose, and a lactose-reduced product should be one with a meaningful reduction. Therefore, the terms lactose-free and lactose-reduced have different meanings, and a lactose-reduced product may still contain lactose that could cause symptoms.

Lactose-free or lactose-reduced products do not protect a person who is allergic to dairy products from experiencing an allergic reaction. People with milk allergies are allergic to the milk protein, which is still present when the lactose is removed.

Look at the ingredient label. If any of these words are listed, the product probably contains lactose:

* milk
* cream
* butter
* evaporated milk
* condensed milk
* dried milk
* powdered milk
* milk solids
* margarine
* cheese
* whey
* curds

Highly sensitive individuals should also beware of foods labeled "non-dairy," such as powdered coffee creamers and whipped toppings. These foods usually contain an ingredient called sodium caseinate, expressed as "caseinate" or "milk derivative" on the label, that may contain low levels of lactose.

Raw Milk and Lactose Intolerance

FDA warns consumers not to drink raw, or unpasteurized, milk. "Raw milk advocates claim that pasteurized milk causes lactose intolerance," says John Sheehan, Director of FDA's Division of Plant and Dairy Food Safety. "This is simply not true. All milk, whether raw or pasteurized, contains lactose, and pasteurization does not change the concentration of lactose nor does it convert lactose from one form into another."

Raw milk advocates also claim that raw milk prevents or cures the symptoms of lactose intolerance. Arguing that raw milk contains Bifidobacteria, they claim these microorganisms are beneficial (probiotic) and create their own lactase, which helps people digest the milk.

"This is not true, either," says Sheehan. "Raw milk can contain Bifidobacteria, but when it does, the bacteria come from fecal matter (animal manure) and are not considered probiotic, but instead are regarded as contaminants."

Drinking raw milk will still cause uncomfortable symptoms in people who are correctly diagnosed as being lactose intolerant. But worse than this discomfort are the dangers of raw milk, which can harbor a host of disease-causing germs, says Sheehan. "These microorganisms can cause very serious, and sometimes even fatal, disease conditions in humans." See more information on the dangers of raw milk.

Points to Remember

* Lactose intolerance is the inability or insufficient ability to digest lactose, a sugar found in milk and milk products.
* Lactose intolerance is caused by a deficiency of the enzyme lactase, which is produced by the cells lining the small intestine.
* Not all people with lactase deficiency have digestive symptoms, but those who do may have lactose intolerance.
* Lactose maldigestion may sometimes be a better term than intolerance since most people with lactose intolerance can tolerate some amount of lactose in their diet. When consumption of liquid dairy products reach a couple of servings per day or more, some individuals will benefit of the use of products with reduced lactose content (hydrolyzed lactose, fermented dairy products).
* Yoghurt is well tolerated by lactose intolerant individuals, even pasteurized yoghurt.
* People with lactose intolerance may feel uncomfortable after consuming milk and milk products. Symptoms can include abdominal pain, abdominal bloating, gas, diarrhea, and nausea.
* Symptoms of lactose intolerance resemble those of some other gastrointestinal dysfunctions such as functional bowel disorders and other maldigestions.
* The symptoms of lactose intolerance can be managed with dietary changes.
* Getting enough calcium and vitamin D is a concern for people with lactose intolerance when the intake of milk and milk products is limited. Many foods can provide the calcium and other nutrients the body needs.
* Talking with a doctor or registered dietitian may be helpful in planning a balanced diet that provides an adequate amount of nutrients—including calcium and vitamin D—and minimizes discomfort. A health professional can determine whether calcium and other dietary supplements are needed.
* Milk and milk products are often added to processed foods. Checking the ingredients on food labels is helpful in finding possible sources of lactose in food products.

For More Information (Sources)

US Food and Drug Administration

"Lactose Intolerance — Vesa et al. 19 (Supplement 2): —." Journal of the American College of Nutrition. Web. 17 Dec. 2009. [http://www.jacn.org/cgi/content/full/19/suppl_2/165S].

American Dietetic Association
120 South Riverside Plaza, Suite 2000
Chicago, IL 60606–6995
Internet: [http://www.eatright.org]

International Foundation for Functional Gastrointestinal Disorders
P.O. Box 170864
Milwaukee, WI 53217–8076
Phone: 1–888–964–2001 or 414–964–1799
Fax: 414–964–7176
Email: gro.dgffi|dgffi#gro.dgffi|dgffi
Internet: [http://www.iffgd.org]

National Digestive Diseases Information Clearinghouse

2 Information Way
Bethesda, MD 20892–3570
Phone: 1–800–891–5389
TTY: 1–866–569–1162
Fax: 703–738–4929
Email: vog.hin.kddin.ofni|ciddn#vog.hin.kddin.ofni|ciddn
Internet: [http://www.digestive.niddk.nih.gov]

The National Digestive Diseases Information Clearinghouse (NDDIC) is a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). The NIDDK is part of the National Institutes of Health of the U.S. Department of Health and Human Services. Established in 1980, the Clearinghouse provides information about digestive diseases to people with digestive disorders and to their families, health care professionals, and the public. The NDDIC answers inquiries, develops and distributes publications, and works closely with professional and patient organizations and Government agencies to coordinate resources about digestive diseases.

References

1. Shils, Maurice E. "Chapter 3: Carbohydrates." Modern Nutrition in Health and Disease. Baltimore: Williams & Wilkins, 1999. 63. Print.

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