What Is Lactose Intolerance and What Causes It?

Lactose intolerance is the inability to digest a sugar called lactosethat is found in milk and dairy products. Normally when a person eats something containing lactose, an enzyme in the small intestine called lactase breaks down lactose into simpler sugar forms called glucose and galactose. These simple sugars are then easily absorbed into the bloodstream and turned into energy fuel for our bodies. People with lactose intolerance do not produce enough of the lactase enzyme to break down lactose. Instead, undigested lactose sits in the gut and gets broken down by bacteria, causing gas, bloating, stomach cramps, and diarrhea. Lactose intolerance is fairly common. It seems to affect guys and girls equally. Some ethnic groups are more likely to be affected than others because their diets traditionally include fewer dairy products: Almost all Asians and Native Americans are lactose intolerant, and up to 80% of African Americans and Hispanic Americans also have symptoms of lactose intolerance. Their ancestors did not eat dairy foods, so their bodies were not prepared to digest dairy, and they passed these genes on from generation to generation. Little kids are less likely to have lactose intolerance. But many people eventually become lactose intolerant in adulthood some while they are still teens. Some health care providers view lactose intolerance as a normal human condition and therefore don't really consider it a disease.

Who Gets Lactose Intolerance?

A person may be or may become lactose intolerant for different reasons:

Ethnic background. People of Asian, African, Native American, and Hispanic backgrounds are more likely to develop lactose intolerance at a young age. Other problems with the digestive tract. People who have inflammation of their upper small intestine, such as celiac or Crohn's disease, have a reduced level of the lactase enzyme. Medications. Certain antibiotics can trigger temporary lactose intolerance by interfering with the intestine's ability to produce the lactase enzyme. Infection. After a bout of infectious diarrhea, some kids can develop a temporary lactose intolerance that usually improves after a few days or weeks. Age. As people get older, their bodies usually stop producing the lactase enzyme, and most people will naturally become lactose intolerant over time.

What Happens When Someone Has Lactose Intolerance?

People with lactose intolerance may have a variety of symptoms. It all depends on how much dairy or how many milk-containing foods the person eats and how little lactase the body produces. Usually within 30 minutes to 2 hours after eating, someone with lactose intolerance will experience nausea, stomach cramps, bloating, gas, and diarrhea. This can be unpleasant, not to mention embarrassing if you're at school or out with friends. Because many people may think they're lactose intolerant when they really aren't, it helps to see a doctor who can diagnose the condition correctly and advise you on ways to manage it.

How Do Doctors Diagnose It?

If your doctor suspects you might be lactose intolerant, he or she will take your medical history by asking about any concerns and symptoms you have, your past health, your family's health, any medications you're taking, any allergies you may have, and other issues. Your doctor will also perform a physical examination. Doctors can test for lactose intolerance by using the hydrogen breath test. Normally very little hydrogen gas is detectable in the breath. However, undigested lactose in the colon ferments (breaks down) and produces various gases, including hydrogen. If your doctor decides to give you a hydrogen breath test, you'll be asked to blow into a tube for a beginning sample. You'll then swallow a drink with lactose in it, wait a while, and breathe into the tube again. You'll be asked to blow into the tube every half hour for 2 hours in order to measure hydrogen levels in your breath. The levels should go up over time if you have lactose intolerance. Doctors also can find out if you're able to digest lactose by testing for the presence of lactase with an endoscopy. During this procedure, doctors view the inside of the intestines by inserting a long tube with a light and a tiny camera on the end into the mouth. A doctor can then take tissue samples and pictures of the inside of your gut and look for clues to why you've been having problems with what you're eating. The amount of lactase enzyme can be measured in one of these tissue samples.

Living With Lactose Intolerance

Lactose intolerance is a very individual condition and it's often easy to manage if you're in tune with your body. Everyone's different, but most people with lactose intolerance are able to eat a small amount of dairy. The trick is to eat dairy products in combination with other foods that don't contain lactose and not eat too much dairy at once. It can also help to keep a food diary to learn which foods your body can or can't tolerate. Dairy foods are the best source of calcium, a mineral that's important for bone growth. Because growing teens need about 1,300 milligrams (mg) of calcium each day, the American Academy of Pediatrics (AAP) recommends that even teens who have lactose intolerance continue to include some dairy in their diet. Foods like cheese or yogurt may be easier to digest than milk, so try a cup of yogurt for dessert or add a piece of cheese to your sandwich. Lactose-free milk is also a great way to get calcium in your diet without the problems that can come with lactose. Taking a lactase enzyme supplement might help, too. Taking this before eating foods that contain dairy will help the body digest the lactose sugar in dairy so you don't develop the symptoms of lactose intolerance, like pain, cramping, bloating, gas, and diarrhea. Teens with the most severe symptoms of lactose intolerance might have to avoid all dairy products. It's extra important that these teens find other good calcium sources, so talking to a registered dietitian is a good idea. Dietitians are trained in nutrition and they can help people who are lactose intolerant come up with eating alternatives and develop a well-balanced diet that provides lots of calcium for developing strong bones.

Here are some tips for dealing with lactose intolerance:

Choose lactose-reduced or lactose-free milk.

Take a lactase enzyme supplement (such as Lactaid) just before you eat dairy products. These can be taken in drops or tablets and even added directly to milk.

When you do drink milk or eat lactose-containing foods, eat other non-lactose foods at the same meal to slow digestion and avoid problems. (For example, if you are going to have a milkshake, don't drink it by itself. Have something else with it, like a healthy sandwich.)

Drink juices that are fortified with calcium. Eat a variety of dairy-free foods that are rich in calcium, such as broccoli, beans, tofu, or soy milk. Consider hard cheeses such as cheddar, which are lower in lactose.

Yogurts that contain active cultures are easier to digest and much less likely to cause lactose problems.

Learn to read food labels. Lactose is added to some boxed, canned, frozen, and prepared foods like bread, cereal, lunchmeats, salad dressings, mixes for cakes and cookies, and coffee creamers. Be aware of certain words that may mean the food has lactose in it: butter, cheese, cream, dried milk, milk solids, powdered milk, and whey, for example. Lactose Intolerance:

Lactose Intolerance (LI) is defined as the inability to completely break down lactose due to a lack or reduced production of lactase enzyme by the small intestines. This is also referred to as Lactase Deficiency. It the most common type of Carbohydrate Intolerance. LI is the commonest genetic disorder affecting more than half the world population. After all, perhaps it is normal to be intolerant and abnormal to be tolerant!

Lactase: enzyme found in microvilli cells of small intestine that hydrolyzes lactose.

Terminology of Lactose Intolerance

The following are terminology differences and possible confounding terms about lactose intolerance:

Lactose maldigestion & lactose malabsorption: are terms to describe a poor lactose hydrolysing capacity without symptoms. Hypolactasia, lactase non-persistence, lactase restriction: means that there is low lactase activity in the jejunal mucosa. Normolactasia, lactase persistence: when there is persistent lactase activity comparable to the neonatal period Lactose Intolerance: should only be used for a clinical entity, describing symptomatic lactose maldigestion (20% of hypolactasic individuals.

Types:
Different reviews and reports group Lactose Intolerance (LI) differently. Some categorise them in two groups while others in three. However, they always refer to the conditions correctly. It is a matter of opinion whether one of the conditions that causes LI fits in one group or is presented in a separate group. I prefer to subdivide LI or Lactase deficiency in three groups as in my opinion this is a more logical way. Hence, there are three groups of Lactase Deficiency:

Congenital Lactase Deficiency: two types of very rare genetic disorders Primary Lactase Deficiency: most common, around 75% of the world population Secondary Lactase Deficiency: caused by a disease or condition and may be only temporary

Congenital Lactase Deficiency

There are two types of Congenital Lactase Deficiency (CLD) and they have identical symptoms. CLD, inherited as an autosomal recessive trait, are rare genetic conditions. In this type there is a marked deficiency of lactase production if any at all in the small intestine from birth. It is caused when a baby inherits two ineffective genes from the parents (one from each). This results in an inability of the genes in the newborn to produce enough lactase or nothing at all. There is abnormal absorption of lactose and other disaccharides from the gastric mucosa. CLD is characterised by severe diarrhoea, abdominal pain, vomiting dehydration, renal tubular acidosis, aminoaciduria, liver damage, lactosuria, cataracts and distension that appear soon after birth when the diet begins to contain lactose. The baby will fail to thrive, but a milk free diet leads to rapid recovery, and after 6 months of age a normal diet with some milk may be tolerated. Blood sugar rises normally after oral administration of glucose or galactose, but not after lactose, which may induce explosive diarrhoea, flatulence and intestinal discomfort. Bacterial fermentation of ingested lactose in the colon leads to high concentrations of lactic acid which make the stool very acidic. The second type, also called Familial Lactase Deficiency is the result of a defective lactase enzyme protein. Unlike CLD the level of lactase enzyme production is normal but since the genes are producing a defective enzyme, lactase is deemed dysfunctional and ineffective. Treatment for both types is initially with a lactose free diet and food treated with commercially available lactase enzymes.

Primary Lactase Deficiency

PLD is usually referred to those persons who do not produce enough lactase after weaning. This type is also called Late Onset Lactase Deficiency. This by far the most popular and accounts for more than half the

world population. However, another type of PLD, not talked about very much is present in premature babies whose underdeveloped small intestines are not mature to produce enough lactase.

Late Onset Lactase Deficiency

Also know as Adult Lactase Deficiency. This is by far the commonest of them all. Late Onset Lactase Deficiency is also considered as the commonest genetical disorder of all disorders (but is it really a disorder?). Enzyme levels are highest shortly after birth and decline with aging, despite a continued intake of lactose. Within the animal world, nonhuman mammals usually lose the ability to digest lactose as they reach adulthood. Some populations of the human species, including those of Asian, South American, and African descent, have a propensity for developing lactase deficiency. By contrast, races descended from northern Europe or from the north-western Indian subcontinent are likely to retain the ability to absorb lactose into adulthood. Late onset lactose intolerance occurs several years after birth and is unlikely to be a problem until after 5 to 7 years of age. Lactose, a disaccharide (two single sugars attached to each other), is present in milk and processed foods. Dietary lactose must be hydrolyzed to a monosaccharide (single sugars) in order to be absorbed by the small intestinal mucosa. A deficiency of intestinal lactase prevents hydrolysis of ingested lactose. The osmotic load of the unabsorbed lactose causes secretion of fluid and electrolytes until osmotic equilibrium is reached. Dilation of the intestine caused by the osmosis induces an acceleration of small intestinal transit, which increases the degree of maldigestion. Within the large intestine, free lactose is fermented by colonic bacteria to yield short-chain fatty acids and hydrogen gas. The combined increase in faecal water, intestinal transit, and generated hydrogen gas accounts for the wide range of gastrointestinal symptoms. Symptoms of lactose intolerance include loose stools, abdominal bloating and pain, flatulence, nausea, and borborygmi. A diagnosis or even the suggestion of lactose intolerance leads many people to avoid milk and/or consume specially prepared food with digestive aids, adding to health care costs.

Development Lactase Deficiency

DLD is the other type of Primary Lactase Deficiency. It results from low lactase levels and is a consequence of prematurely born babies. Lactase activity start during late gestation periods. Hence, a prematurely born baby will acquire lactose intolerance due to lack of enzyme production. The list below shows the activity of lactase in the foetus as it increases with gestation:

23rd week 10% of full term between 25th and 34th is 30% of full term between 34th and 35th week 70% of full term

Premature infants born at 28 to 32 weeks of gestation have reduced lactase activity that will lead to severe cramps, abdominal pains, diarrhoea,

It is common for premature babies to be lactase deficient. As they develop most of them will be able to start producing enough lactase.

continuous discomfort and crying. These symptoms may be very similar to babies suffering form baby colic. Lactose free milk, or milk treated with lactase enzyme should alleviate the symptoms.

Secondary Type Lactase Deficiency

Secondary lactase deficiency can result from small intestinal resections, and from gastrectomy and from diseases that damage the intestinal epithelium, e.g. untreated coeliac disease or intestinal inflammation. Another source of secondary type lactase deficiency is a long course of antibiotics. When the epithelium

heals, the activity of lactase returns. However, according to American Journal of Clinical Nutrition, Vol 60, 926-929, Arrigoni et al. secondary maldigestion does not automatically lead to severe symptoms of intolerance. The following is a list of intestinal diseases that may cause a secondary type lactase deficiency: Giardiasis: Coeliac sprue: Diabetic gastropathy: HIV enteropathy: Gastrinoma: - Ascariasis: - Tropical sprue: - Carcinoid syndrome: - Kwashiorkor: - Crohn disease: - Radiation sprue: - Whipple syndrome: - Chemotherapy:

Symptoms:

Abdominal pain - cramps, often localised to the per-umbilical area or lower quadrant Bloating - caused by the formation of gases that expand in the warm conditions of the digestive system Flatulence - caused by the gases produced by the bacteria. H2S is the gas associated with the odour Borborygmi - may be audible to the patient and on physical examination Diarrhoea - stools are usually bulky, frothy and watery Vomiting - particularly adolescents Nausea - may be present, probably due to acidity and gases escaping backwards Weight loss - if kept unattended Malnutrition - especially in babies