Lactase Non-persistence and Lactose Intolerance
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Purpose of Review
To evaluate the clinical and nutritional significance of genetically determined lactase non-persistence and potential lactose and milk intolerance in 65–70% of the world’s adult population.
Milk consumption is decreasing in the USA and is the lowest in countries with a high prevalence of lactase non-persistence. The dairy industry and Minnesota investigators have made efforts to minimize the influence of lactose intolerance on milk consumption. Some lactose intolerant individuals, without co-existent irritable bowel syndrome, are able to consume a glass of milk with a meal with no or minor symptoms. The high frequency of lactase persistence in offspring of Northern European countries and in some nomadic African tribes is due to mutations in the promoter of the lactase gene in association with survival advantage of milk drinking.
Educational and commercial efforts to improve calcium and Vitamin D intake have focused on urging consumption of tolerable amounts of milk with a meal, use of lowered lactose-content foods including hard cheeses, yogurt, and lactose-hydrolyzed milk products.
KeywordsLactase non-persistence Lactose intolerance Lactase persistence Evolution, positive selection Milk drinking
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent
This review contains published papers that presumably met journal standards for publication.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 3.•• Bayless TM, Rosensweig NS. A racial difference in incidence of lactase deficiency. JAMA. 1966;197(19):138–42. Second most widely cited gastroenterology paper in JAMA in 50 year period. Reference #4 was the most cited. Google Scholar
- 6.Ransome-Kuti B. Personal communication. 1996Google Scholar
- 10.•• Simoons FJ. Primary lactose intolerance and the milking habit: a problem in biological and cultural interrelationships. II. A culture historical hypothesis. Am J Dig Dis. 1970;15:695–710. The leader in recognizing the role of dairying and milk consumption in the development of lactase persistence CrossRefPubMedGoogle Scholar
- 12.•• Simoons FJ. Lactose digestion. Clinical and nutritional implications. In: Paige DM, Bayless TM, editors. Geographic patterns of primary adult lactose malabsorption. A further interpretation of evidence for the old world. Baltimore: Johns Hopkins University Press; 1981. p. 23–48. The first text on lactose intolerance.Google Scholar
- 18.• Dzialanski Z, Barany M, Engfeldt MA, Olsson LA, Nilsson TK. Lactase persistence versus lactose intolerance: is there an intermediate phenotype? Clinbiochem. 2016;49:248–52. Describes heterozygotes.Google Scholar
- 21.• Awuah B, Yaa N, Fleet S, et al. Functional significance of single nucleotide polymorphisms in the lactase gene in diverse US patents and evidence for a novel lactase persistence allele at -13909 in those of European ancestry. J Pediatr Gastroenterol Nutr. 2015;60:182–91. Useful study from Boston Pediatrics.CrossRefGoogle Scholar
- 27.•• Paige DM. Lactose intolerance. Encyclopedia of Human Nutrition (Third Edition). 2013:67–73. An excellent review of the nutritional implications.Google Scholar
- 29.•• Silanikove N, Leitner G, Merin U. The interrelationships between lactose intolerance and the modern dairy industry: global perspectives in evolutional and historical backgrounds. Nutrients. 2015a;7:7312–31. Excellent global perspective on the dairy industry.CrossRefPubMedPubMedCentralGoogle Scholar
- 40.•• Bayless TM, Christopher NL, Boyer SH. Autosomal recessive inheritance of intestinal lactase deficiency: evidence from ethnic differences. J Clin Invest. 1969:48–6a. Described lactase deficiency as a recessive trait. Google Scholar
- 43.• Paz-y-Mino C, Burgos G, Lopez-Cortes A, et al. A study of the molecular variants associated with lactase persistence in different Ecuadorian ethnic groups. Am J Human Biol. 2016;0:1–11. Shows effects of genetic admixture on lactase polymorphism.Google Scholar
- 45.•• Yang J, Deng Y, Chu H, et al. Prevalence and presentation of lactose intolerance and effects on dairy product intake in healthy subjects and patients with irritable bowel syndrome. Clin Gastro Hepatol. 2013;11:262–8. A good study of the role of co-existent IBS in a population with universal lactase non-persistence. CrossRefGoogle Scholar
- 51.•• Shaukat A, Levitt MD, Taylor BC, MacDonald R, Shamilyan TA, Kane RL, Witt TJ. Systematic review: effective management strategies for lactose intolerance. Ann Intern Med. 2010;152:797–803. Reviews placebo controlled trials and tends to minimize the clinical importance of lactose intolerance. CrossRefPubMedGoogle Scholar
- 52.•• Suchy GJ, Brannon PM, Carpenter TO, et al. National Institutes of Health consensus development conference: lactose intolerance and health. Ann Intern Med. 2010;152:792–6. Reviews placebo controlled trials and tends to minimize the clinical importance of lactose intolerance. CrossRefPubMedGoogle Scholar
- 53.•• Erickson J, Sadeghirad B, Lytyvn L, Slavin J, Johnston BC. The scientific basis of guideline recommendations on sugar intake: A systematic review. Ann Intern Med 2016; Dec 20. Doi 10.7326/M16-2020. A highly criticized attempt by the sugar industry to minimize the importance of sugar in obesity be altering definitions and selecting biased studies, reminiscent of the efforts by the tobacco and dairy industries.
- 54.Paige, DM & Graham, GG, "Nutritional Implications of Lactose Malabsorption", Pediatric Research abstract 6:329, 1972.Google Scholar
- 55.Paige, DM, Bayless, TM, and Graham, GG, "Pregnancy and Lactose Intolerance," American Journal of Clinical Nutrition, 26:238–240, March, 1973.Google Scholar
- 56.Leichter, J, "Effects of Lactose on the Absorption of Other Nutrients" in Paige, DM, & Bayless, TM, Editors: "Lactose Digestion: Clinical and Nutritional Implications", The Johns Hopkins University Press, Baltimore, Maryland, P.142–147,1981.Google Scholar
- 59.• Szilagyi A. Adaptation to lactose in lactase non persistent people: effects on intolerance and the relationship between dairy food consumption and evaluation of diseases. Nutrients. 2015b;7:6751–79. An important look at dairy food consumption and adaptation to continued small amounts of lactose. CrossRefPubMedPubMedCentralGoogle Scholar
- 61.•• Briet F, Pochart P, Marteau P, Flourie B, Arrigoni E, Rambaud JC. Improved clinical tolerance to chronic lactose ingestion in subjects with lactose intolerance: a placebo effect? Gut. 1997;41:632–5. Poor paper. Used 50 grams of lactose, equivalent to a quart of milk, as the challenge! CrossRefPubMedPubMedCentralGoogle Scholar
- 62.• Bohner CJ, Tuynman HA. The effect of a lactose-restricted diet in patients with a positive lactose tolerance test, earlier diagnosed as irritable bowel syndrome: a 5-year follow-up study. Eur J Gastroenterol Hepatol. 2001;13:941–4. A good early study of the role of lactose intolerance in some patients with IBS. CrossRefGoogle Scholar
- 63.Zhu Y, Zheng X, Cong Y, Chu H, Fried M, Dai N, Fox M. Bloating and distention in irritable bowel syndrome: the role of gas production and visceral sensation after lactose ingestion is a population with lactase deficiency. Am J Gastroenterol. 2013;10:1516–25. A good pathophysiologic study of the reasons for exaggerated symptoms of lactose intolerance in subjects with co-existent IBS. CrossRefGoogle Scholar
- 64.• Arguelles-Arias F, Rodriguez-Ledo, Tenias JM et al. The management of lactose intolerance among primary care physicians and its correlation with management by gastroenterologists: the SEPD=SEMG national survey. Rev Esp Enfirm Dig (Madrid) 2015;107:554–559. Spanish gastroenterologists considered lactose intolerance a minor condition and saw it as overlapping with IBS. Google Scholar
- 65.• Ferdman RA. The mysterious case of America’s plummeting milk consumption. The Washington Post June 20.2014. A reporter’s view of milk consumption.Google Scholar
- 66.• Sebastian RD, Goldman JD, Wilkinson Enns C, LaComb, RP. Fluid milk consumption in the United States: What we eat in America. NHANES 2005–2006. Food Surveys Research Group. Dietary Data Brief No.3. Sept 2010. Major data on milk consumption from the government.Google Scholar
- 67.•• Shrier I, Szilagyi A, Correa JA. Impact of lactose containing foods and the genetics of lactase on diseases: an analytical review of population data. Nut Cancer. 2008;60:292–300. Shows prevalence of lactase non-persistence in a country’s population correlates with the amount of dairy food consumption. CrossRefGoogle Scholar
- 68.Paige DM, Bayless TM, Ferry GD, Graham GG. Lactose malabsorption and milk rejection in Negro children. Johns Hopkins Med J. 1971;20:163–70.Google Scholar
- 69.Paige DM, Bayless TM, Graham GG. Milk programs: helpful of harmful to Negro children? Am J Pub Health. 1972;62:486–8.Google Scholar
- 70.• Almon R, Sjostrom M, Nillsson TK. Lactase non-persistence as a determinant of milk avoidance and calcium intake in children and adolescents. J Nutr Sci. 2013;2:e26. doi: 10.1017/jns2013.11.Linked LMP and decreased dairy intake.
- 72.• Baadkar SV, Mukherjee MS, Lele SS. Study on influence of age, gender and genetic variants on lactose intolerance and its impact on milk intake in adult Asian Indians. Hum Biol. 2014;41:548–53. Linked LMP and diminished dairy ingestion.Google Scholar
- 75.• Heaney RP. Dairy intake, dietary adequacy and lactose intolerance. Adv Nutr. 2013;4:151–60. Concern for decreased dairy intake and relation to lactose intolerance.Google Scholar
- 77.• Opstelten JL, Leenders M, Dik VK, et al. Dairy products, dietary calcium and risk of inflammatory bowel disease: results from a European prospective cohort investigation. Inflam Bowel Dis/. 2016;22:1402–11. Risk of dietary calcium inadequacy in Inflammatory Bowel Disease Google Scholar