Digestive Diseases and Sciences

, Volume 54, Issue 5, pp 1059–1065 | Cite as

Development, Validation, and Applicability of a Symptoms Questionnaire for Lactose Malabsorption Screening

  • Francesc CasellasEmail author
  • E. Varela
  • A. Aparici
  • M. Casaus
  • P. Rodríguez
Original Article


Lactase deficiency has a high prevalence worldwide. Thus, a valid symptom scale would be a useful tool for identifying patients with lactose malabsorption. Objective To develop, validate, and apply a symptoms questionnaire on lactose malabsorption to identify lactose malabsorbers diagnosed with the gold-standard hydrogen breath test. Methods In the first part of the study, 292 patients completed a questionnaire at the end of a 50-g lactose breath test. The questionnaire included five items (diarrhea, abdominal cramping, vomiting, audible bowel sounds, and flatulence or gas) scored on a 10-cm visual analogue scale. In the second part of the study, 171 patients completed the questionnaire twice: first, according to their opinion when consuming dairy products at home and second, after a 50-g lactose breath test. Patients were grouped as absorbers or malabsorbers according to the result of the breath test. Results Diarrhea, abdominal cramping, and flatulence were scored significantly higher in malabsorbers than in absorbers. Total score of the symptomatic questionnaire was significantly higher in malabsorbers (17.5 versus 3.0, P < 0.01). According to receiver operator characteristics (ROC) analysis, the most discriminant cut-off of the total score to identify lactose malabsorption was 6.5 (sensitivity 0.75, specificity 0.67). In 58 malabsorbers the effect size of the questionnaire to determine sensitivity to change was 1.32. In the second part of the study, scoring of the home questionnaire was higher than after the lactose-breath test. The lactose malabsorbers rate was higher according to the home questionnaire than after the lactose breath test (72% versus 52%). The home questionnaire had excellent sensitivity (0.82) but low specificity (0.35). Conclusion We developed and validated a five-item symptoms questionnaire for lactose malabsorption. This is a valid test that permits patients with a total score lower than 7 to be excluded from future studies.


Hydrogen breath test Lactose breath test Lactose intolerance Lactose malabsorption Symptoms score 



We thank Miss. Christine O’Hara for valuable contributions to the English revision of this manuscript. Ciberehd is funded by the Instituto de Salud Carlos III, Spain. This work was supported in part by grants from the Generalitat de Catalunya (RE: 2001SGR00389) and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd, Spain).


  1. 1.
    Peña A, Peña JF. Malabsorción de lactosa en estudiantes españoles. Tolerancia intestinal a la sobrecarga oral de lactosa. Rev Esp Enferm Dig. 1971;35:925–938.Google Scholar
  2. 2.
    Carnicer J. Malabsorció de lactosa en una població preescolar i escolar. But Soc Cat Pediatr. 1993;53:26–32.Google Scholar
  3. 3.
    Vázquez C. Malabsorción de los hidratos de carbono en el niño: malabsorción de la lactosa. Esp Ped. 1975;8:166–178.Google Scholar
  4. 4.
    Leis R, Tojo R, Pavón P, Douwes A. Prevalence of lactose malabsorption in Galicia. J Ped Nutr. 1997;25:296–300. doi: 10.1097/00005176-199709000-00009.CrossRefGoogle Scholar
  5. 5.
    Sahi T. Hypolactasia and lactase persistence. Historical review and terminology. Scand J Gastroenterol. 1994;29(suppl 202):1–6, 994. doi: 10.3109/00365529409091739.
  6. 6.
    Melvin BH and the Committee on Nutrition. Lactose intolerance in infants, children and adolescents. Pediatrics. 2006;118:1279–1286. doi: 10.1542/peds.2006-1721.Google Scholar
  7. 7.
    Bond JH, Levitt MD. Quantitative measurement of lactose absorption. Gastroenterology. 1976;70:1058–1062.PubMedGoogle Scholar
  8. 8.
    Di Palma JA, Narvaez RM. Prediction of lactose malabsorption in referral patients. Dig Dis Sci. 1988;33:303–307. doi: 10.1007/BF01535754.CrossRefGoogle Scholar
  9. 9.
    Suarez FL, Savaiano DA, Levitt MD. A comparison of symptoms after the consumption of milk or lactose-hydrolyzed milk by people with self-reported severe lactose intolerance. N Engl J Med. 1995;333:1–4. doi: 10.1056/NEJM199507063330101.PubMedCrossRefGoogle Scholar
  10. 10.
    Pelletier X, Laure-Boussuge S, Donazzolo Y. Hydrogen excretion upon ingestion of dairy products in lactose-intolerant male subjects: importance of the live flora. Eur J Clin Nutr. 2001;55:509–512. doi: 10.1038/sj.ejcn.1601169.PubMedCrossRefGoogle Scholar
  11. 11.
    Vermia P, Di Camillo M, Marinaro V. Lactose malabsorption, irritable bowel syndrome and self-reported milk intolerance. Dig Liver Dis. 2001;33:234–239. doi: 10.1016/S1590-8658(01)80713-1.CrossRefGoogle Scholar
  12. 12.
    Vonk RJ, Priebe MG, Koetse HA, et al. Lactose intolerance: analysis of underlying factors. Eur J Clin Invest. 2003;33:70–75. doi: 10.1046/j.1365-2362.2003.01099.x.PubMedCrossRefGoogle Scholar
  13. 13.
    Pimentel M, Kong Y, Park S. Breath testing to evaluate lactose intolerance in irritable bowel syndrome correlates with lactulose testing and may not reflect true lactose malabsorption. Am J Gastroenterol. 2003;98:2700–2704. doi: 10.1111/j.1572-0241.2003.08670.x.PubMedCrossRefGoogle Scholar
  14. 14.
    Suarez FL, Savaiano DA. Lactose digestion and tolerance in adult and elderly Asian-Americans. Am J Clin Nutr. 1994;59:1021–1024.PubMedGoogle Scholar
  15. 15.
    Hermans MM, Brummer RJ, Ruijgers AM, Stocbrügger RW. The relationship between lactose tolerance test results and symptoms of lactose intolerance. Am J Gastroenterol. 1997;92:981–984.PubMedGoogle Scholar
  16. 16.
    Peuhkuri K, Vapaatalo H, Nevala R, Korpela R. Temperature of a test solution influences abdominal symptoms in lactose tolerance tests. Scand J Clin Lab Invest. 2000;60:75–80. doi: 10.1080/00365510050185065.PubMedCrossRefGoogle Scholar
  17. 17.
    Casellas F, Malagelada JR. Applicability of short hydrogen breath test for screening of lactose malabsorption. Dig Dis Sci. 2003;48:1333–1338. doi: 10.1023/A:1024163327183.PubMedCrossRefGoogle Scholar
  18. 18.
    Casado A, Prieto L, Alonso J. El tamaño del efecto de la diferencia entre dos medias: ¿estadísticamente significativo o clínicamente relevante? Med Clin (Barc). 1999;112:584–588.Google Scholar
  19. 19.
    Bullinger M, Anderson R, Cella D, Aaronson N. Developing and evaluating cross-cultural instruments from minimum requirements to optimal models. Qual Life Res. 1994;2:451–459. doi: 10.1007/BF00422219.CrossRefGoogle Scholar
  20. 20.
    Iqbal TH, Bradley R, Reilly KO, Cooper BT. Small intestinal lactase status, frequency distribution of enzyme activity and milk intake in a multi-ethnic population. Clin Nutr. 1996;15:297–302. doi: 10.1016/S0261-5614(96)80003-3.PubMedCrossRefGoogle Scholar
  21. 21.
    Gupta SK, Chong SKF, Fitzgerald JF. Disaccharidase activities in children: normal values and comparison based on symptoms and histologic changes. J Pediatr Gastroenterol Nutr. 1999;28:246–251. doi: 10.1097/00005176-199903000-00007.PubMedCrossRefGoogle Scholar
  22. 22.
    Leis R, Tojo R, Pavón P, Douwes A. Prevalence of lactose malabsorption in Galicia. J Pediatr Gastroenterol Nutr. 1997;25:296–300. doi: 10.1097/00005176-199709000-00009.PubMedCrossRefGoogle Scholar
  23. 23.
    Vernia P, Camillo M, Marinaro V, Caprilli R. Lactose malabsorption and the genesis of irritable bowel syndrome symptoms. Gastroenterology. 2001;120(Suppl 1):A264.Google Scholar
  24. 24.
    Martini MC, Savaiano DA. Reduced intolerance symptoms from lactose consumed during a meal. Am J Clin Nutr. 1988;47:57–60.PubMedGoogle Scholar
  25. 25.
    He T, Priebe MG, Harmsen HJ, et al. Colonic fermentation may play a role in lactose intolerance in humans. J Nutr. 2006;136:58–63.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2008

Authors and Affiliations

  • Francesc Casellas
    • 1
    Email author
  • E. Varela
    • 1
  • A. Aparici
    • 1
  • M. Casaus
    • 1
  • P. Rodríguez
    • 1
  1. 1.Digestive System Research UnitHospital Universitari Vall d’HebronBarcelonaSpain

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