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Lactose intolerance

lactofree

PHC643 Holmes S (2005) Lactose intolerance. Primary Health Care. 16, 1, 41-50.
Date of acceptance: November 28 2005.

Aim and intended learning outcomes

This article provides an overview of lactose intolerance, considering its origins and development
and its role in determining the diet affected
individuals can tolerate. After reading this article
readers should be able to Identify how they will
apply what they have learned into their clinical
practice and be able to:
Summarise the normal digestion and absorption of dietary disaccharides
Describe the aetiology of lactose intolerance
and distinguish between congenital, primary
and secondary types of the condition
Identify patients who may be affected by lactose intolerance and be able to take appropriate action to alleviate its symptoms
Discuss the dietary problems that patients
may face in trying to identify an appropriate
and nutritionally adequate diet.
Introduction
Failure to absorb lactose (milk sugar) in the
small intestine results in gastrointestinal (Gl)
symptoms such as diarrhoea and the passage of
loose, watery stools, abdominal pain, excessive
flatus and bloating. Although this is generally a
life-long condition (primary lactose intolerance)
it may also be the temporary result of, for example, an infection or other insult to the intestinal
mucosa (secondary lactose intolerance); rarely it
may be a congenital condition.

In brief

To be absorbed effectively, lactose requires

the presence of lactase, an enzyme present at
the intestinal brush border (National Digestive
Diseases Information Clearinghouse (NDDIC)
1994) particularly in the jejunal mucosa (Buller
and Grand 1990). It is deficiency (hypolactasia)
or absence (alactasia) of lactase that causes
lactose intolerance. While not all those who
are lactase deficient have symptoms, those
who do are considered to be lactose intolerant.
Recognition and early diagnosis is essential as
the condition, though rarely serious, may be
very distressing. It is easily managed by relatively
simple dietary modification significantly alleviating patient anxiety and improving the quality of
the patient's life.

What is lactose?
Milk and other dairy products uniquely contain
lactose, a disaccharide comprising two simple
molecules - glucose and galactose, It is the
principal sugar present in milk and found only
in the mammary glands of lactating mammals:
4-6 per cent in cows' milk and 5-8 per cent in
human milk. It is less soluble than the other
common disaccharides (maltose and sucrose)
and only about one-sixth as sweet as sucrose
(table sugar) and so may be used to increase
the calorie content of, for example, nutritional
supplements without making them unpleasantly
sweet. However, as it is difficult to dissolve, this
is not always practical.

Author
Susan Holmes BSc, PhD, SRN,
FRSH,CMS, Director of Research
and Development, Professor of
Nursing, Faculty of Health and
Social Care, Canterbury Christ
Church University, Canterbury.
Summary
This article outlines the genesis
and aetiology of lactose intolerance, a common disorder causing significant gastrointestinal
distress worldwide. Approaches
to diagnosis and management
are presented, with particular
emphasis on the nutritional
aspects of patient care.
Key words
Lactose intolerance
Lactase deficiency
Disaccharides
Caidum
Dietary management
These key words are based
on subject headings from the
British Nursing Index. This
article has been subject to
double-blind review.
Online archive
For related articles visit
our online archive at:
www.primaryhealthcare.net
and search using the key
words above.

primary health care | Vol 16 No 1 | February 2006 41

To be absorbed and used by the body, all disaccharides must first be broken down (hydrolysed)
by digestive enzymes into their constituent
sugars prior to absorption into the bloodstream
through the intestinal mucosa, primarily the
jejunum. From here they pass to the liver,
through the portal vein, and are transported to
body tissues and used as an energy source.
Now do Time Out 1

TIME OUT 1
Look up the anatomy and physiology
of the digestive tract and identify the
areas where lactase is produced and
digestion and absorption of lactose
occurs. Using this information, identify
those conditions in which lactose
intolerance is likely to occur as an
acquired condition.

Digestion and absorption

Lactose hydrolysis primarily takes place in the
jejunum, resulting in the production of glucose
and galactose which are then readily absorbed.
Many people, however, lack sufficient levels of
lactase, preventing the breakdown of ingested
lactose at least some of which passes into the
large intestine where it has an osmotic effect
and draws water into the colon.
In addition, unhydrolysed lactose is fermented
by the intestinal flora, primanly lactobacilli, to
produce lactic acid and other organic acids,
short-chain fatty acids, carbon dioxide, hydrogen gas and methane (Castiglia 1994). It is
these that cause the symptoms of lactose
intolerance. This surprisingly common disorder
causes a range of unpleasant symptoms such as
flatulence, bloating, diarrhoea and abdominal
pain. However, diagnosis - or even the suggestion - of lactose intolerance leads many
people to avoid milk and/or consume foods
specially prepared using digestive aids, adding
to healthcare costs and increasing the risk of
inappropnate nutrition.

Prevalence of lactose intolerance

Lactase deficiency is common in late childhood
and adult life in most populations worldwide,
ranging from less than 5 per cent to more than
90 per cent, depending on the population {Sahi
1994). Indeed, Kretchmer (1981) proposed fhat
it is lactose intolerance that is the 'normal' state;
lactose tolerance is the abnormal condition.
Lactose intolerance is least common among
Caucasians and highest among populations
in the Far Fast (Sahi 1994). In the United
States, the prevalence of lactose malabsorption

42 primary health care | Vol 16 No 1 | February 2006

is about 15 per cent in Caucasians, 53 per cent

in Mexican Americans, 80 per cent in African
Americans, and 90 per cent in Asian-Americans
(Sahi 1994).
In 1978, it was estimated that the incidence of
lactose maldigestion in Europe ranged between
11 and 60 per cent (Simoons 1978) stabilising around 15 per cent in Northern Europeans
(Swagerty ef al 2002). The relationship between
such maldigestion and clinical symptoms is,
however, unclear and many of those affected
can tolerate small quantities of milk without
developing any symptoms (Rosado etal 1992).

Genesis of lactose intolerance

Lactase activity increases during late gestation,
reaching a maximum at full term and remaining high until weaning when milk is no longer
the major part of the diet (Antonowicz ef al
1974, Grand et al 1976). In common with all
land mammals, however, human lactase levels
decline dramatically after weaning so that
90-95 per cent of birth lactase levels are lost
by early childhood. Lactase levels continue to
decline with age (McBean and Miller 1998,
Swagerty ef al 2002); the prevalence of lactose
intolerance is significantly higher in those over
50 years (46 per cent) than in younger individuals (26 per cent) (Rao ef a/ 1994). Although the
reasons for this are unclear, pnmary lactose
deficiency appears to be a normal phenomenon as age increases (Shukia 1997, McBean
and Miller 1998).
The transition from tolerance of lactose to
lactose intolerance generally starts between
two and 15 years of age, depending largely on
cultural and racial background. For example, in
Greek and Israeli children, prevalence increases
linearly between the ages of five and 12 years
(Bujanover ef al 1985), while in South Afncan
children of Indian origin the onset is at ten years
or older compared with that of native South
Africans in whom the condition starts between
the ages of five and ten years (Wittenberg and
Moosa 1990); Chinese, Jamaican and Peruvian
children display lactose intolerance between
three and five years of age (Paige et al 1972,
Chang ef al 1987). Such developmental differences between races are not fully understoodHowever, even today a relationship can be
shown between milk production across the
world and the prevalence of lactose intolerance
showing that production is low in areas of high
lactose intolerance when compared with those
with a high population of lactose tolerance; thus
milk consumption offers a fair indication of the
prevalence of lactose intolerance in different
regions (Shukia 1997).

lactose intolerance

Aetiology of lactose intolerance

Childhood and adult onset lactase deficiency
are inherited in an autosomal recessive manner
while persistent lactase activity into adulthood
is an autosomal dominant trait. For most of
those affected, lactose intolerance develops
naturally as age increases. Such intolerance
(primary lactose intolerance (hypolactasia)) is
by far the most common and means that many
people who are otherwise healthy must avoid a
range of nutritionally valuable foods containing
mitk and/or whey solids; this may have notable
nutritional consequences. There are, however,
two other forms of the condition: congenital
lactose intolerance and secondary lactose intolerance; the latter may be a permanent or a
transient state.
Congenital lactose intolerance, due to alactasia (absence of lactase), is a very rare inherited
disorder (Welsh and Griffiths 1980). Affected
babies are born healthy but the symptoms
present as soon as breast milk or cows' milk
formula is consumed (Johnson 1981). In such
infants, failure to thrive, fluid and electrolyte
imbalance, a bloated, protuberant abdomen,
diarrhoea and weight loss are the usual presenting symptoms. Though the condition is rare, failure to diagnose it correctly in the early days of
life can be fatal as affected infants may become
rapidly dehydrated (Shukia 1997).
Secondary (acquired) lactose intolerance
(hypolactasia) develops in those with a previously healthy intestinal tract and can follow any
condition that damages the intestinal brush
border or which significantly increases transit
time through the jejunum (Swagerty ef a/2002).
It is not, therefore, affeaed by factors such as
age and race. Secondary hypolactasia can result
from intestinal resection, gastrectomy (Welsh
and Griffiths 1980) and from conditions that
damage the intestinal epithelium (Table 1) (Bode
and Gudmand-Hoyer 1988, Pironi etal 1988).
When the epithelium recovers, lactase activity
- and lactose tolerance - generally returns to
normal. The severity of the condition varies and
depends upon the degree of damage to the
intestinal mucosa.

Table 1. Some causes of secondary (acquired) lactose intolerance

Small bowel
HIV enteropathy
Regional enteritis
Coeliac disease
Tropical sprue
Severe gastroenteritis

latrogenic
Cancer chemotherapy
Radiation enteritis

Multisystem disorders
Carcinoid syndrome
Cystic fibrosis
Diabetic gastropathy
Kwashiokor
Zoilinger-Ellison syndrome

in turn, increases the extent of maldigestion.

The combined increase in faecal water, intestinal transit and the presence of gases increases
osmotic pressure within the colon and accounts
for the range of symptoms arising within 30
minutes and two hours of ingestion of lactose
(NDDIC 1994).
The severity of the symptoms experienced,
however, varies according to the quantity of
lactose consumed, how much lactase activity
remains in the Gl tract and the amount of lactose individuals can tolerate. The degree of tolerance is affected by several factors including
age and ethnic origin; older patients are more
susceptible to both primary and secondary lactose intolerance (Lloyd and Olsen 1995). Small
to moderate amounts of lactose, however,
usually cause flatulence, bloating and cramping
but less often result in diarrhoea; increasingly
larger quantities contribute to increasingly
severe symptoms.
Now do Time Out 2

TIME OUT 2
A patient has approached you about
their 'gut function'. They have regular
diarrhoea associated with abdominal
cramps and bloating. What questions
will you ask to help you to reach
a tentative diagnosis? Using the
information given in the next section
what tests would then be used to
confirm this?

Clinical features
Hypolactasia results in up to 75 per cent of
dietary lactose passing from the small intestine
to the colon in an unhydrolysed state where
it is rapidly metabolised by the intestinal flora,
primarily lactobacilli, to produce organic acids
and gases (Shaw and Davies 1999). It also
draws fluid into the gut causing dilation and
acceleration of small intestinal transit which.

Diagnosis
The medical history is likely to reveal feelings
of abdominal fullness and bloating, nausea,
abdominal pain, diarrhoea and flatulence, particularly after consuming milk or dairy products.
These symptoms are non-specific and may be
easily confused with those of irritable bowel
syndrome and a range of other inflammatory

primary health care | Vol 16 No 1 | February 2006 43

lactose intolerance

Table 2. Differential diagnoses for patients

with lactose intolerance

Irritable bowel syndrome

Regional enteritis/Crohn's disease
Uleerative colitis
Cystic fibrosis
Diverticular disease
Coeliac disease
Tropical sprue
Parasitic diseases {for example, ascariasis,
giardiasis)
Viral or bacterial infections
Inadvertent ingestion of laxatives or ingestion
of bran
intestinal conditions {Table 2). Lactose intolerance cannot be diagnosed on the basis of
symptoms alone (Arola et al 1994, Vesa ef al
1996). Consideration of differential diagnoses
is important.
Secondary lactose intolerance may be present
in a variety of Gl diseases in which there is
evidence of mucosal damage. Inflammatory
bowel syndrome, for example, is a benign but
distressing condition of complex multifactorial
pathology (Read 1994); it has much in common
with lactose intoierance and, indeed, the two
conditions have similar symptom complexes.
Establishing a secure diagnosis can be difficult
as patients with IBS often report intolerance to
food, particularly dairy products {Drossman et
al 1997). Furthermore, at least 25 per cent of
those with IBS also have lactose malabsorption
(Tolliver et a! 1994). However, because lactose
intolerance is organic rather than functional, it
differs fundamentally from IBS. Despite this, lactose restriaion may lead to symptom improvement in both groups of patients (Swagerty eta!
2002). It is important that patients with secondary lactose intolerance are investigated further
to identify the primary problem; effective treatment may overcome lactose intolerance.

and other food products - in infancy may result

from increased intestinai permeability and the
immaturity of the immune system (Horst 1994).
Tolerance to breast milk, therefore, suggests that
the reaction is not due to lactose but rather an
allergic response to cows' milk proteins; indeed,
breast milk is believed to confer protection
against such allergy by enhancing development
of the intestinal epithelium (Strobe! 1996).
It should be made clear to patients that having
lactose intolerance does not mean that they are
allergic to milk or dairy products/foods.
Diagnostic tests
The most common tests used to diagnose
lactose intolerance involve measuring lactose
absorption in the digestive system.
The Iacto5e tolerance test involves administering an oral dose of lactose and monitoring
blood glucose levels. The patient fasts overnight before a baseline serum glucose level is
obtained. A dose of lactose (usually 50g) is then
administered; serial blood samples are taken
over a two-hour period. The test is positive if
intestinal symptoms occur and blood glucose
levels Increase less than 20mg/dl (I.immol/L)
above the fasting level indicating that lactose
hydrolysis is impaired. A dose of 50g lactose
produces symptoms in 70-80 per cent of those
intolerant to lactose while 10-15g will cause
abdominal symptoms in oniy 30-60 per cent
(Ferguson and Griffin 2000). False positive and
false negative results may, however, occur in 20
per cent of normal subjects due to variations in
gastric emptying time and glucose metabolism.
False-negative results may also occur in the
presence of diabetes and/or small intestinal
bacterial overgrowth.

Acquired lactose intolerance may also be

confused with milk allergy since the symptoms
improve when milk is removed from the diet.
This condition results from an allergic reaction
to one or both of the proteins present in milk
(casein and lactalbumin) and is very different from lactose intolerance as the response
is mediated by immunoglobulin E; antibodies to milk may be found in the bloodstream
(Ferguson and Griffin 2000). Symptoms of
lactose intolerance are generally limited to the
intestine while those of milk allergy may affect
almost any area of the body; nausea, vomiting
and colic are more likely.

The hydrogen breath test is the diagnostic

test of choice as it is more sensitive and specific than the lactose tolerance test. It is based
on the following principle: the body does not,
normally, produce hydrogen; many bacteria
(including the intestinai flora) generate hydrogen in the presence of a suitable metabolic
substrate. In the absence of digestive disorders,
carbohydrate absorption is usually complete in
the jejunum and no sugars enter the colon and
no additional hydrogen is produced. However,
in cases of lactase deficiency, undigested lactose is fermented by colonic bacteria, and various gases, including hydrogen, are produced.
This is absorbed into the bloodstream from
where it enters the lungs and is exhaled; the
level of hydrogen excreted in the breath can
then be measured.

It has been suggested that the relatively high

incidence of adverse reactions to cows' milk -

The procedure is that the patient dnnks a lactose-loaded beverage; expired air samples are

44 primary health care j Vol 16 No 1 | February 2006

lactose intolerance

collected before and at 30-minute intervals for

three hours after administration to assess hydrogen concentrations; raised levels of exhaled
hydrogen (greater than 20 parts per million)
indicate lactase deficiency. False-negative results
may be seen when the intestinal flora has been
reduced by recent antibiotic therapy or high
colonic enemas (Swagerty ef a! 2002).
Lactose tolerance and hydrogen breath tests
are not used in infants and very young children
who are suspected of having lactose intolerance
as the large lactose load may be dangerous
due to the dehydration that can result from the
resultant diarrhoea. If a baby or young child is
experiencing symptoms of lactose intolerance,
many paediatricians simply recommend changing from cows' milk to soy formula and waiting
for symptoms to abate.
If this is not sufficient, however, a stool acidity test, which measures the amount of acid
present in the faeces, may be used, particularly
in younger age groups. Bacterial fermentation
of undigested lactose in the colon creates lactic
acid and other organic acids that can be detected in the stools; glucose may also be present
due to unabsorbed lactose in the colon. Such
tests are not entirely reliable and are not recommended for routine use (Vesa et a! 2000).
Nutritional consequences and benefits
Since milk and other dain/ products are major
contributors to the diet, the amount of lactose
consumed by some individuals may be significant; intolerance to lactose may, therefore,
disrupt individual nutritional status. This is particularly relevant with regard to calcium though,
in cases of diarrhoea, absorption of all nutrients
may be reduced. This is an issue in those who
diagnose lactose intolerance for themselves in
the absence of medical advice and/or support.
Indeed, those who exclude all dietary lactose
and dairy products from their diet put themselves at risk for calcium-related diseases including osteoporosis. Evidence suggests that those
avoiding milk and other dairy products, and
who also have reduced caicium consumption,
fail to develop peak bone mass, particularly
dunng adolescence, and are at enhanced risk
of osteopenia and, hence, osteoporosis in later
life (Corazza et al 1995, Di Stefano et al 2002).
Low milk consumption in older lactose intolerant adults may also contribute to osteoporosis,
though this has not been confirmed (Wheadon
etal 1991).
It is also postulated that milk and dairy products may be involved in a wide range of biological effects over and above their established role
in bone health. They may, for example, improve

blood pressure, decrease the risk of certain types

of cancer, enhance immunity, improve intestinal
health, prevent the formation of renal calculi and enhance nutrient absorption (Hoolihan
2002); omission may, therefore, have significant
health implications.
Conversely, there is some suggestion that
lactose intolerance may be protective against
certain diseases. For example, although not
confirmed, some studies demonstrate that milk
consumption by those in whom lactase persists
into adult life is associated with an increased risk
of cataracts (Simoons 1982, Rinaldi et al 1984).
Similarly, there are suggestions of a link between
the ability to digest lactose and ovarian cancer
(Cramer 1989, Cramer et al 1994, Larsson et
al 2004) suggesting that lactose intolerance is
protective since this would reduce the presence
of galactose which may be toxic to the human
oocyte (Chen et al 1981, Swartz and Mattison
1988); again this remains to be confirmed.
Now do Time Out 3

TIME OUT 3
It is important that patients are
provided with readily accessible dietary
information to help them to manage
their condition. Before reading the
next section, consider what aspects
of nutrition and diet you would
include in a patient information leaflet
for those with lactose intolerance.
Consider also what format you will
use, how long your leaflet will be and
the 'language' you will use to ensure
that it is 'patient-friendly'.

Management of lactose intolerance

In cases of secondary lactase deficiency, treatment
of the primary condition often results in a return
to normal; short-term dietary measures may,
however, be required. In cases of primary lactase
deficiency, though no treatment can enhance the
ability to produce lactase, the condition is readily
managed by dietary manipulation, consumption
of a low lactose or lactose-free diet. However,
because milk is such an important component
of the diet the diagnosis should be confirmed
before such a diet is recommended.
A lactose-free diet means the complete
avoidance of cows', goat's and sheep's milk as
well as dairy products such as butter, cheese,
cream, yoghurt and milk derivatives. As milk
and milk products are rich sources of protein,
calcium, carbohydrate and a range of other
nutrients, the nutritional consequences of
lactose intolerance may be significant, even
lethal, in infants and young children unless
other dietary sources are used. Nutritionally

primary health care | Vol 16 No 1 | February 2006 45

lactose intolerance

Table 3. Food products that may contain

'hidden lactose'
Bread and other baked goods
Non-dairy creamer
Processed breakfast cereals
Instant potatoes, soups, and breakfast drinks
Margarine
Lunch meats (other than kosher)
Salad dressings
Sweets, milk chocolate, instant hot chocolate
drinks
Crisps and other snacks
Mixes for pancakes, biscuits and cakes
Powdered meal-replacement supplements
and 'slimming foods'

complete milk substitutes can help many

youngsters. Calcium can be obtained from
dark green leafy vegetables or from the bones
of small sardines, anchovies or whitebait consumed whole {Kretchmer 1993) as well as, in
some cases, cheese and live yoghurt.
The strictness of the diet depends upon individual susceptibility to the effects of lactose; this
varies significantly. Most patients do not require
a totally lactose-free or severely restricted diet
(Suarez et al 1995, 1998) as the symptoms of
intolerance are dose-dependent (Hertzler ef al
1996). In general, young children with lactase
deficiency should not consume any foods containing lactose, while many older children and
adults need not avoid lactose completely. Studies
have shown that, in those who have at ieast
some intestinal lactase production, tolerance to
lactose can be increased when dairy products
are gradually introduced into the diet (Johnson
et al 1993). For example, prolonged consumption of non-pasteurised yoghurt appeared to
improve lactose digestion after six and 12 days,
while diarrhoeal symptoms reduced after 12
days (Pochart et al 1989). Similarly, when milk
is consumed with other foods, lactose digestion may improve (Martini and Savaiano 1988,
Dehkordi etal 1995).
Individuals vary in the amounts and types
of foods they can tolerate. For example, one
person may develop symptoms after dnnking a
small glass of milk while another may tolerate
one glass but not two. Others may be able to
manage ice cream and aged cheeses (such as
Cheddar) but not other dairy products. This is
because, during the cheese-making process,
some of the lactose present in milk is converted
to lactic and other acids contributing to the
development of flavour; the lactose content
may be significantly reduced. The effect is that
many cheeses contain little or no lactose and
may be tolerated by lactase-deficient individuals.

46 primary health care | Vol 16 No 1 | February 2006

the notable exceptions being cream and cottage cheeses. Lactose, however, remains in the
whey which, sold as a commercial by-product of
cheese manufacture, is incorporated into many
manufactured goods; care is therefore needed
to avoid 'hidden' lactose.
Live yoghurt (containing live bacterial cultures),
although containing some lactose, may also be
tolerated by some people as the lactose has
been fermented and/or broken down by bacterialiy derived lactases (Saltzman et a! 1999). This
means that, for many, dietary control depends
on learning through trial and error how much
iactose they can handle.
For those who react to very small amounts of
lactose or who have trouble limiting their intake,
lactase enzymes are available and can enhance
lactose digestion. The tablets are taken immediately before consuming lactose or, in the case
of liquid preparations, added to milk or cream to
'pre-digest' lactose thus making it more digestible. Enzyme supplementation shouid be used
with caution as it may not relieve symptoms due
to incomplete digestion of lartose or because it
is difficult to ascertain the amount of the enzyme
required. It should be used as an adjunct to
dietary manipulation and not as a substitute for
dietary control {Swagerty eta! 2002).
Lactose-reduced milk and other products are
now widely available and can help many sufferers to gain the benefits of milk-based products
(Ramirez et al 1994). Care must be taken -particularly in infants or young children - since milk
IS an important source of not only protein and
calcium but also ribofiavin (vitamin B^, vitamin
D, vitamin A, phosphorus and magnesium. It is
important that nutritionally complete milk substitutes are used in this situation. Such products
are prescribable for those who are intolerant
of milk or lactose or who have galactosaemia;
a list of those currently available can be found
in the British National Formulary or MIMS.
Nutritionally incomplete milks are often available from health food stores and supermarkets;
they do not provide the same nutrients as milk
and cannot be considered to be milk replacements but may be useful adjuncts to the diet
of older children and adults (Thomas 1994).
An alternative approach is to use milk to which
lactase has been added.

Hidden lactose
Although milk and foods made from milk are
the only natural sources, lactose may also be
found in many food products (Table 3) and in
some brands of monosodium glutamate, low
calorie sweeteners and some crisps, stock cubes
and dried/powdered soups (Thomas 1994).

lactose intolerance

Those with a very low tolerance should know

about the many products that may contain even
small amounts of lactose. Products labelled
'non-dairy', such as powdered coffee creamer
and whipped toppings, may be derived from
milk and so contain lactose. Ingredients such
as casein, whey, skimmed milk, non-fat milk
solids and hydrolysed whey - and words such
as curds, milk by-products, dry milk solids, and
non-fat milk powder - indicate the presence of
lactose meaning that labels must be carefully
scrutinised if this is to be avoided. The British
Dietetic Association (www.bda.uk.com) provides lists of milk-free manufactured foods. This
rapidly becomes out-of-date due to changes in
product formulation or the introduction of new
Items (Thomas 1994).

ment therapy, for example, contain lactose, as

do some antacids and indigestion remedies.
However, these products typically affect only
people with severe lactose intolerance.
Now do Time Out 4

Lactose is also used as a filler by some pharmaceutical companies so that almost any tablets
may contain lactose which is used in more than
20 per cent of prescription drugs and about 6
per cent of over-the-counter medicines. Many
types of birth control pills and hormone replace-

Milk and other dairy products are major sources

of nutrients in the diet; the most important of
these is calcium. Calcium is the most abundant
mineral in the body, comprising approximately
1.5-2.0 per cent of body weight. Ninety-nine
per cent of this is present in 'hard' tissues such

TIME OUT 4
What is the major nutritional problem
associated with low lactose and
lactose-free diets? Using an appropriate
text book confirm the possible impact
this can have on normal physiological
processes and the potential health
problem this can cause.

Dietary problems

Table 4. Calcium content of some foods (mg per lOOg)

Whitebait

860

Sardines (canned, in oil)

550

Sardines (canned, in tomato sauce)

460

Whitebait

860

Shrimps (boiled)

320

Toasted bread

110

Muesli

200

Cream crackers

110

Gingerbread

210

Steamed sponge pudding

210

Spinach (boiled)

600

Spring onions

80

Watercress

220

Savoy cabbage

75

Spring greens

80

Leeks

61

Stewed rhubarb (with sugar)

84

Parsnips

55

Potato crisps

20

Dried figs

280

Cheddar-type cheese

800

Blue cheeses

580

Natural yoghurt

180

Almonds

252

Brazil nuts

180

Dried apricots

92

Fruit gums

360

Olives tn brine

61

primary health care | Vol 16 No 1 | February 2006 47

lactose intolerance

as bones and teeth; the remaining one per cent

is present in the blood, extracellular fluids and
in body cells where it regulates many metabolic
processes such as enzyme function, muscle
contraction and blood clotting.
Calcium is assimilated more easily from some
foods than from others. For example, the calcium in milk is assimilated readily due to the
presence of lactose and vitamin D. Though
the reasons for this are not entirely clear, one
hypothesis suggests that it may be that a relatively high ratio of lactose to calcium enables
formation of a complex between the sugar
and caicium enabling calcium to be more readily transported across the intestinal mucosa.
It is also possible that the lactose-calcium
complex prevents calcium from precipitating
as the intestinal contents change from acid
to alkaline during their transit through the Gl
tract (Alvioli 1972).
Now do Time Out 5

Planning a nutritious diet

Calcium is essential for the growth and repair
of bones throughout life. In the middle and
later years, calcium deficiency may lead to
osteoporosis. Although the Estimated Average
Requirements (EAR) for calcium vary across the
world, all adults require an intake of at least
525mg per day (Table 4); this is higher during

REFERENCES

Alvioli LV (1972) Intestinal absorption of calcium Archives of Internal

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48 primary health care | Vol 16 No 1 | February 2006

TIME OUT 5
Scrutinise the labels on a range of
food produrts and convenience foods.
How easy is it to determine
the presence of lactose? Using this
information, construct a daily diet for
a- a working mother
b. a growing child
c. an old person with chewing and/or
swallowing difficulties
Now look at the patient information
sheet that you devised earlier and
ensure that you have included all the
relevant information. Have you, for
example, considered the problem of
'hidden' lactose or the need to ensure
an adequate calcium intake?

pregnancy and periods of active growth (such

as adolescence). This means that, wherever
possible, dairy products should not be totally
eliminated from the diet.
In planning meals, it is important to ensure
that the daily diet includes enough calcium
even if no dairy products are included. Many
non-dairy foods are high in calcium, including
some green vegetables (Table 5). However,
the calcium in some vegetables (for example, Swiss chard, spinach, rhubarb) is not
readily available to the body as they also
contain oxalates, which inhibit its absorption.

Ferguson A, Griffin GE (2000)

Nutrition and the immune system.
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DA (1996) How much lactose is low
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Hoolihan L (2002) Beyond calcium, the
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lactose intolerance

Table S. Estimated Average Requirements

for calcium (UK)
Age
0-12 months
1-3 years
7-10 years
Males
11-14 years
19-50 years
50-1- years
Females
11-14 years
19-50 years
50+ years
During pregnancy and lactation

EAR
(mg/day)
400
275
425
750
525

525
625
525
525
+ 550

Furthermore, calcium is only absorbed in the

presence of sufficient vitamin D in the body; a
balanced diet should also provide an adequate
supply of this vitamin. Sources of vitamin D
include eggs and liver. Sunlight helps the body
naturally absorb or synthesise vitamin D, and
with enough exposure to sunlight, food sources may not be necessary. Consultation with
a dietician may help in pianning meals that
will provide the most nutrients with the least
chance of causing discomfort and in deciding
whether dietary supplements are needed by
individual patients.

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fears and fallacies about lactose
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GE (1994) Prevalence of lactose maldigestion: influence and interaction of
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Summary
Even though lactose intolerance is widespread.
It need not pose a serious threat to health for
the majority of those affected. Patients soon
learn which dairy products and other foods
tbey can eat without discorTifort and which they
should avoid and, witb help and guidance from
healthcare professionals, plan a nutritionally
adequate diet. Many will be able to enjoy milk,
ice cream, and other such products if they take
tbem in small amounts or eat other food at the
same time. Others can use enzyme supplements
to help lactose digestion. The key to successful
management is talking to affected patients and
helping tbem to identify an appropriate diet.
Even older women at risk for osteoporosis
and growing children wbo must avoid milk and
foods made with milk can meet most of tbeir
nutrient needs by eating greens, fish and other
calcium-rich foods tbat are free of lactose. A
carefully chosen diet, with calcium supplements
if necessary, is the key to reducing symptoms
and protecting future bealth.
Now do Time Out 6

TIME OUT 6
Now that you have read this article
you migbt like to try to write a practice
profile. Guidelines to help you can be
found on page 50.

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