Osteoporosis International

, Volume 18, Issue 4, pp 445–451 | Cite as

Adult-type hypolactasia and calcium availability: decreased calcium intake or impaired calcium absorption?

  • B. M. Obermayer-PietschEmail author
  • M. Gugatschka
  • S. Reitter
  • W. Plank
  • A. Strele
  • D. Walter
  • C. Bonelli
  • W. Goessler
  • H. Dobnig
  • C. Högenauer
  • W. Renner
  • A. Fahrleitner-Pammer
Original Article



Adult-type hypolactasia, as mediated by a widespread genetic predisposition, not only reduces calcium intake but also calcium absorption in the presence of high amounts of lactose and may, therefore, promote osteoporosis. A lactose-reduced diet and lactose-free calcium supplements may reverse this imbalance.

Introduction and hypothesis

Adult-type hypolactasia (HL) defined by the LCT(−13910) polymorphism may reduce calcium intake by reducing dairy consumption and, therefore, promote osteoporosis. This study aimed to evaluate whether lactose also decreases intestinal calcium absorption in subjects with HL and whether lactose-reduced diet and lactose-free calcium supplementation as recommended could maintain bone mineral density (BMD).


Based on LCT genotyping, 73 postmenopausal women with and without HL underwent a conventional H2 breath test with a concomitant oral strontium absorption test lasting 150 minutes, which closely reflects intestinal calcium absorption. In addition, we compared bone-specific laboratory parameters, lumbar and femoral BMD, and spinal radiographs to a similar bone assessment 5 years earlier.


LCT genotyping and functional lactose malabsorption tests were highly correlated. Dairy product consumption was reduced by 80% in HL individuals. During concomitant lactose application, mean strontium absorption was blunted by 54% in HL subjects after 150 minutes (1272 ± 629 μg/L vs. 2020 ± 1130 μg/L in lactose tolerant subjects, p = 0.001). Nevertheless, BMD in HL subjects remained stable with lactose-free calcium supplements during the observation period.


Both decreased calcium intake as well as lactose-associated impaired calcium absorption may predispose subjects with HL to osteoporosis. Lactose-free calcium supplementation may help to maintain BMD in HL subjects.


Calcium absorption Genetic testing Hypolactasia Lactose intolerance Osteoporosis Polymorphism 


  1. 1.
    Sahi T (1994) Genetics and epidemiology of adult-type hypolactasia. Scand J Gastroenterol 202:7–20Google Scholar
  2. 2.
    Jackson KA, Savaiano DA (2001) Lactose maldigestion, calcium intake and osteoporosis in African-, Asian- and Hispanic-Americans. J Am Coll Nutr 20(2):198S–270SPubMedGoogle Scholar
  3. 3.
    Birge SJ Jr, Keutmann HT, Cuatrecasas P, Whedon GD (1967) Osteoporosis, intestinal lactase deficiency and low dietary calcium intake. N Engl J Med 276(8):445–448PubMedCrossRefGoogle Scholar
  4. 4.
    Slemenda CW, Christian JC, Hui S, Fitzgerald J, Johnston CC Jr (1991) No evidence for an effect of lactase deficiency on bone mass in pre- or postmenopausal women. J Bone Miner Res 6(12):1367–1371PubMedGoogle Scholar
  5. 5.
    Honkanen R, Kroger H, Alhava E, Turpeinen P, Tuppurainen M, Saarikoski S (1997) Lactose intolerance associated with fractures of weight-bearing bones in Finnish women aged 38–57 years. Bone 21(6):473–477PubMedCrossRefGoogle Scholar
  6. 6.
    National Institutes of Health Consensus Statement (1994) Optimal calcium intake. Bethesda, MD: National Institutes of Health 94:6–8; 12:1–31Google Scholar
  7. 7.
    Heaney RP (2000) Calcium, dairy products and osteoporosis. J Am Coll Nutr 19:83S–99SPubMedGoogle Scholar
  8. 8.
    Obermayer-Pietsch BM, Bonelli CM, Walter DE, Kuhn R, Fahrleitner-Pammer A, Berghold A, Goessler W, Stepan V, Dobnig H, Leb G, Renner W (2004) Genetic predisposition for adult lactose intolerance and relation to diet, bone density, and bone fractures. J Bone Miner Res 19(1):42–47PubMedCrossRefGoogle Scholar
  9. 9.
    Enattah NS, Sahi T, Savilahti E, Terwilliger JD, Peltonen L, Jarvela I (2002) Identification of a variant associated with adult-type hypolactasia. Nat Genet 30(2):233–237PubMedCrossRefGoogle Scholar
  10. 10.
    Kuokkanen M, Enattah NS, Oksanen A, Savilahti E, Orpana A, Jarvela I (2003) Transcriptional regulation of thelactase-phlorizin hydrolase gene by polymorphisms associated with adult-type hypolactasia. Gut 52(5):647–652PubMedCrossRefGoogle Scholar
  11. 11.
    Högenauer C, Hammer HF, Mellitzer K, Renner W, Krejs GJK, Toplak H (2005) Evaluation of a new DNA test compared with the lactose hydrogen breath test for the diagnosis of lactase non-persistence. Eur J Gastroenterol Hepatol 17(3):371–376PubMedCrossRefGoogle Scholar
  12. 12.
    Hammer HF, Fine KD, Santa Ana CA, Porter JL, Schiller LR, Fordtran JS (1990) Carbohydrate malabsorption. Its measurement and its contribution to diarrhea. J Clin Invest 86(6):1936–1944PubMedCrossRefGoogle Scholar
  13. 13.
    Obermayer-Pietsch BM, Bonelli CM, Walter DE, Kuhn R, Fahrleitner-Pammer A, Berghold A, Goessler W, Stepan V, Dobnig H, Leb G, Renner W (2004) Genetic components of lactose intolerance and community frequency. J Bone Miner Res 19(10):1747CrossRefGoogle Scholar
  14. 14.
    Matthews SB, Waud JP, Roberts AG, Campbell AK (2005) Systemic lactose intolerance: a new perspective of an old problem. Postgrad Med J 81(953):167–173PubMedCrossRefGoogle Scholar
  15. 15.
    Schaafsma G, Visser R (1980) Nutritional interrelationships between calcium, phosphorus and lactose in rats. J Nutr 10(6):1101–1111Google Scholar
  16. 16.
    Zittermann A, Bock P, Drummer C, Scheld K, Heer M, Stehle P (2000) Lactose does not enhance calcium bioavailability in lactose-tolerant, healthy adults. Am J Clin Nutr 71(4):931–936PubMedGoogle Scholar
  17. 17.
    Sips AJ, Netelenbos JC, Barto R, Lips P, van der Vijgh WJ (1994) One-hour test for estimating intestinal absorption of calcium by using stable strontium as a marker. Clin Chem 40(2):257–259PubMedGoogle Scholar
  18. 18.
    Blumsohn A, Morris B, Eastell R (1994) Stable strontium absorption as a measure of intestinal calcium absorption: comparison with the double-radiotracer calcium absorption test. Clin Sci (Lond) 87(3):363–368Google Scholar
  19. 19.
    Reid IR, Pybus J, Lim TM, Hannon S, Ibbertson HK (1986) The assessment of intestinal calcium absorption using stable strontium. Calcif Tissue Int 38(5):303–305PubMedCrossRefGoogle Scholar
  20. 20.
    Barger-Lux MJ, Heaney RP (2005) Calcium absorptive efficiency is positively related to body size. J Clin Endocrinol Metab 90(9):5118–5120PubMedCrossRefGoogle Scholar
  21. 21.
    Cochet B, Jung A, Griessen M, Bartholdi P, Schaller P, Donath A (1983) Effects of lactose on intestinal calcium absorption in normal and lactase-deficient subjects. Gastroenterology 84:935–940PubMedGoogle Scholar
  22. 22.
    Nordin BE, Need AG, Morris HA, O’Loughlin PD, Horowith M (2004) Effect of age on calcium absorption in postmenopausal women. Am J Clin Nutr 80(4):998–1002PubMedGoogle Scholar
  23. 23.
    Heaney RP, Recker RR, Stegman MR, Moy AJ (1989) Calcium absorption in women: relationships to calcium intake, estrogen status, and age. J Bone Miner Res 4(4):469–475PubMedCrossRefGoogle Scholar
  24. 24.
    Gallagher JC, RApuri PB, Haynatzki G, Detter JR (2002) Effect of discontinuation of estrogen, calcitriol, and the combination of both on bone density and bone markers. J Clin Endocrinol Metab 87(11):4914–4923PubMedCrossRefGoogle Scholar
  25. 25.
    Dawson-Hughes B (2003) Interaction of dietary calcium and protein in bone health in humans. J Nutr 133(3):852–854Google Scholar
  26. 26.
    Krall EA, Dawson-Hughes B (1999) Smoking increases bone loss and decreases intestinal calcium absorption. J Bone Miner Res 14(2):215–220PubMedCrossRefGoogle Scholar
  27. 27.
    Di Stefano M, Veneto G, Malservisi S, Strocchi A, Corazza GR (2001) Lactose malabsorption and intolerance in the elderly. Scand J Gastroenterol 36(12):1274–1278PubMedCrossRefGoogle Scholar
  28. 28.
    Goulding A, Taylor RW, Keil D, Gold E, Lewis-Barned NJ, Williams SM (1999) Lactose malabsorption and rate of bone loss in older women. Age Ageing 28(2):175–180PubMedCrossRefGoogle Scholar
  29. 29.
    Enattah NS, Sulkava R, Halonen P, Kontula K, Jarvela I (2005) Genetic variant of lactase-persistent C/T-13910 is associated with bone fractures in very old age. J Am Geriatr Soc 53(1):79–82PubMedCrossRefGoogle Scholar
  30. 30.
    Obermayer-Pietsch BM, Bonelli CM, Walter DE, Kuhn R, Fahrleitner-Pammer A, Berghold A, Goessler W, Stepan V, Dobnig H, Leb G, Renner W (2004) Genetic disposition for adult lactose intolerance and relation to bone properties and fractures during lifetime. Calcif Tissue Int 74(S1):128Google Scholar
  31. 31.
    Enattah N, Valimaki VV, Valimaki MJ, Loyttyniemi E, Sahi T, Jarvela I (2004) Mlecularly defined lactose malabsorption, peak bone mass and bone turnover rate in young finnish men. Calcif Tissue Int 75(6):488–493PubMedCrossRefGoogle Scholar
  32. 32.
    Enattah N, Pekkarinen T, Valimaki MJ, Loyttyniemi E, Jarvela I (2005) Genetically defined adult-type hypolactasia and self-reported lactose intolerance as risk factors of osteoporosis in Finnish postmenopausal women. Eur J Clin Nutr 9(10):1105–1111CrossRefGoogle Scholar
  33. 33.
    French MR, Moore K, Vernace-Inserra F, Hawker GA (2005) Factors that influence adherence to calcium recommendations. Can J Diet Pract Res 6(1):25–29Google Scholar
  34. 34.
    Gugatschka M, Dobnig H, Fahrleitner-Pammer A, Pietschmann P, Kudlacek S, Strele A, Obermayer-Pietsch B (2005) Molecularly-defined lactose malabsorption, milk consumption and anthropometric differences in adult males. QJM 98(12):857–863PubMedCrossRefGoogle Scholar
  35. 35.
    Kanis JA, Johansson H, Oden A, De Laet C, Johnell O, Eisman JA, McCloskey E, Mellstrom D, Pols H, Reeve J, Silman A, Tenenhouse A (2005) A meta-analysis of milk intake and fracture risk: low utility for case finding. Osteoporosis Int 16(7):799–804CrossRefGoogle Scholar
  36. 36.
    Teegarden D, Legowski P, Gunther CW, McCabe GP, Peacock M, Lyle RM (2005) Dietary calcium intake protects women consuming oral contraceptives from spine and hip bone loss. J Clin Endocrinol Metab 90(9):5127–5133PubMedCrossRefGoogle Scholar
  37. 37.
    Hertzler SR, Huynh BC, Savaiano DA (1996) How much lactose is low lactose? J Am Diet Assoc 96(3):243–246PubMedCrossRefGoogle Scholar
  38. 38.
    Ridefelt P, Hakansson LD (2005) Lactose intolerance: lactose tolerance test versus genotyping. Scand J Gastroenterol 40(7):822–826PubMedCrossRefGoogle Scholar
  39. 39.
    Cummings SR, Melton LJ III (2002) Epidemiology and outcomes of osteoporotic fractures. Lancet 359(9319):1761–1767PubMedCrossRefGoogle Scholar
  40. 40.
    Seely S (2000) Possible connection between milk and coronary heart disease: the calcium hypothesis. Med Hypotheses 54(5):701–703PubMedCrossRefGoogle Scholar
  41. 41.
    Rasinpera H, Forsblom C, Enattah NS, Halonen P, Salo K, Victorzon M, Mecklin JP, Jarvinen H, Enholm S, Sellick G, Alazzouzi H, Houlston R, Robinson J, Groop PH, Tomlinson I, Schwartz S Jr, Aaltonen LA, Jarvela I, FinnDiane Study Group (2005) The C/C-13910 genotype of adult-type hypolactasia is associated with an increased risk of colorectal cancer in the Finnish population. Gut 54(5):643–647PubMedCrossRefGoogle Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2006

Authors and Affiliations

  • B. M. Obermayer-Pietsch
    • 1
    Email author
  • M. Gugatschka
    • 1
  • S. Reitter
    • 1
  • W. Plank
    • 1
  • A. Strele
    • 3
  • D. Walter
    • 1
  • C. Bonelli
    • 1
  • W. Goessler
    • 4
  • H. Dobnig
    • 1
  • C. Högenauer
    • 2
  • W. Renner
    • 5
  • A. Fahrleitner-Pammer
    • 1
  1. 1.Division of Endocrinology and Nuclear Medicine, Department of Internal MedicineMedical University of GrazGrazAustria
  2. 2.Division of Gastroenterology and HepatologyMedical University of GrazGrazAustria
  3. 3.Center for Medical Research, Unit of BiostatisticsMedical University of GrazGrazAustria
  4. 4.Institute of Chemistry-Analytical ChemistryKarl-Franzens UniversityGrazAustria
  5. 5.Clinical Institute of Medical and Chemical Laboratory DiagnosticsMedical University of GrazGrazAustria

Personalised recommendations