The traditional dogma: Milk Avoidance and Milk • Lactose maldigesters are lactose intolerant Alternatives • They need to avoid milk • Use digestive aids • Take supplements • Eat low lactose alternatives Dennis Savaiano, PhD • Don’t worry about lower calcium intakes and Virginia C. Meredith Professor of poor bone health Nutrition Science Purdue University savaiano@purdue.edu Reality of the science Scientific reality Lactose Intolerance • Perceived lactose (milk) intolerance causes Low Calcium (real or perceived) milk avoidance intake 5 - 40% -200 to -300 mg/day • Milk avoidance causes low CA intakes and of maldigesters poor bone health • Lactose maldigestion is easily managed with regular single servings of milk with meals Increased fracture Low BMD rate
Dietary Management of LM Intolerance vs. maldigestion • Dose • Self described intolerant, n=30 • Timing of dose • 21 maldigesters, 9 digesters • Colon adaptation • Randomized, double blinded • Residual mammalian lactase • Milk vs Lactose hydrolyzed milk • Food sources vary in lactose • One cup (12g lactose) with breakfast daily for one week • Meal feeding and lactose intolerance • Psychological factors (learned aversion) NEJM 333(1):1-4, 1995 Self-described intolerant maldigesters, n=21 Self-described intolerant digesters, n=9 Symptom Milk Hydrolyzed Difference 95% CI Symptom Milk Hydrolyzed Difference 95% CI Milk Milk Bloating # 0.6 +/- 0.1 0.5 +/- 0.1 0.1 +/- 0.1 -0.2 to 0.4 Bloating # 0.6 +/- 0.2 0.5 +/- 0.2 0.2 +/- 0.2 -0.3 to 0.7 Abdominal 0.6 +/- 0.2 0.4 +/- 0.2 0.2 +/- 0.1 0.0 to 0.4 Abdominal 0.4 +/- 0.1 0.3 +/- 0.1 0.1 +/- 0.1 -0.1 to 0.3 pain # pain # Diarrhea 0.3 +/- 0.2 0.2 +/- 0.1 0.1+/- 0.2 -0.4 to 0.6 Diarrhea 0.1 +/- 0.0 0.3 +/- 0.1 -0.2 +/- 0.1 -0.4 to 0.0 (episodes/day) (episodes/day) Flatus severity# 0.9 +/- 0.2 1.2 +/- 0.2 0.3 +/- 0.2 -0.2 to 0.8 Flatus severity# 1.1 +/- 0.1 0.9 +/- 0.1 0.2 +/- 0.1 0.0 to 0.4 Flatus 11.8 +/- 2.3 8.4 +/- 1.9 3.4 +/- 1.7 -0.53 to 7.3 Flatus 10.1 +/- 1.5 7.6 +/- 1.2 2.5 +/- 1.1 0.2 to 4.8 (episodes/day) (episodes/day) # 0 to 5 ranking of symptoms: 0 none, 1 trivial, 2 mild, 3 moderate, 4 strong, 5 severe # 0 to 5 ranking of symptoms: 0 none, 1 trivial, 2 mild, 3 moderate, 4 strong, 5 severe
Tolerance to two cups of milk Five servings of dairy per day = 1500mg Calcium (Suarez et al 1998) Symptom Baseline Lactose Hydrolyzed Conventional • Self-reported intolerant Excessive gas • One cup with breakfast and one with dinner Maldigesters 0.5 +/- 0.1 a 0.8 +/- 0.2 a 1.3 +/- 0.2 b Digesters 0.4 +/- 0.1 0.4 +/- 0.1 0.4 +/- 0.1 • Very modest increase in symptoms with Bowl movements lactose vs. hydrolyzed milk Maldigesters 1.3 +/- 0.1 a 1.6 +/- 0.2 b 1.8 +/- 0.2 c Digesters 1.3 +/- 0.1 1.4 +/- 0.1 1.3 +/- 0.1 • Self-reported intolerants systematically Diarrhea reported more symptoms regardless of the Maldigesters 0.02 +/- 0.02 0.11 +/- 0.08 0.17 +/- 0.09 Digesters 0.07 +/- 0.05 0.07 +/- 0.04 0.02 +/- 0.01 lactose content of the milk Total flatus AJCN 65: 1502-6, 1997 Maldigesters 10.6 +/- 2.0 a 10.7 +/- 1.3 a 17.1 +/- 2.1 b Digesters 13.7 +/- 1.9 12.8 +/- 1.5 14.7 +/- 1.9 Meta analysis to estimate the occurrence of lactose intolerance in blinded and • 1553 citations from MEDLINE under MeSH controlled studies: heading of LI 1/96 – 1/02 • 108 identified as related to the primary aim with • Cross over designs with lactose-free or low lactose ‘healthy’ subjects product • 53 additional articled identified from secondary • Physiological dose (< 25g) literature • Blinding • Overall 21 studies eligible for inclusion based on • Symptoms reported by frequency or occurrence the criteria • 11 studies reported ‘severity’ of symptoms • Subjects > 4 years of age J Nutr 2006:136:1107-1113
Summary: dietary management Summary: GI physiology Residual Colonic • Lactose intolerance is dose related Lactase Fermentation • One serving of milk is typically well tolerated Activity with a meal • Many dairy foods are well tolerated (yogurts) • Colon adaptation significantly improves Diet Lactose lactose tolerance GI Transit Lactose Tolerance Effect • Lactose intolerance should not be an impediment to adding dairy foods to the diet
Perceived Lactose Intolerance Perceived Milk Intolerance Is Related to Bone Mineral Content in 10- to 13-Year-Old Female Lactose Challenge Questionnaire Adolescents-Matlik et al 2007 ●258 girls completed the Perceived Milk Intolerance 1.) I am allergic to milk questionnaire ( 10-13 yrs of age) 2.) Milk makes my stomach hurt after I drink it ●230 girls completed breath hydrogen testing ●28% Asian, 33% Hispanic, 39% non-Hispanic white 3.) I have been told that milk will make my stomach ●43% were maldigesters hurt after I drink it ● 47 considered themselves to be milk intolerant Strongly Disagree (1) Strongly Agree (5) 20 were maldigesters, 22 were digesters. Do Not Know (0) Perceived and true lactose intolerance Perceived and true lactose intolerance Lactose Maldigestion (LM) Results Non- Asian Participants Hispanic Participants Asian Hispanic Hisp Total n=65 n=76 White 48.7% 51.3% 30.8% n (%) LM LM Completed PLI questionnaire 47 77 92 216 (64) (79) (76) (74) 69.2% Non-Hispanic White Participants Positive for PLI 11 12 20 43 n=89 (23) (15) (21) (20) 15.7% LM Positive for LI 1 5 5 11 (1.5) (6.6) (5.6) (4.8) 84.3% Digester Maldigester 2 =47.489, df=2, P <.0001
Dietary calcium intake was not related to Bone status as BMC was not related to lactose maldigestion status. lactose maldigestion status. Lactose Digestion Dependent Variables P -value Coefficient (95% CI) 1 Lactose Digestion Total body BMC (g) 30.88 (-45.01 to 106.82) .424 Dependent Variables P -value Coefficient (95% CI) 1 Spine (L2-L4) BMC (g) -0.12 (-1.94 to 1.71) .898 Total food calcium (mg) -6 ± (-184 to 172) .945 Total hip BMC (g) 0.21 (-0.83 to 1.26) .689 Dairy calcium (mg) 9 ± (-121 to 139) .889 Femoral neck BMC (g) 0.078 (-0.08 to 0.23) .317 1 Lactose digester coded as 1, Lactose maldigester coded as 0. Thus, negative indicates lower intake among lactose digesters. Adjusted for location (state), race/ethnic group, weight, and age. 1 Lactose digester coded as 1, Lactose maldigester coded as 0. Thus, negative indicates lower value among lactose digesters. Adjusted for location (state), race/ethnic group, BMI, Tanner score and age. Matlik et al. Pediatrics Sept 2007 Matlik et al. Pediatrics Sept 2007 Dietary calcium intake was related Bone status as BMC was related to perceived milk intolerance. to perceived milk intolerance. PMI Coefficient PLI Coefficient 1 Dependent Variables P -value (95% CI) 1 Dependent Variables P -value Total food calcium (mg) -212 (-394 to -29) .023 Total body BMC (g) -69.65 (-147.7 to 8.5) .080 Dairy calcium (mg) -168 (-303 to -34) .015 Spine (L2-L4) BMC (g) -2.52 (-4.4 to -.64) .009 Non-dairy calcium (mg) -23 (-61 to 14) .222 Total hip BMC (g) -0.95 (-2.05 to 0.15) .089 Total dairy (dairy + mixed) (mg) -188 (-352 to -24) .025 Femoral neck BMC (g) -0.14 (-0.3 to 0.02) .083 Servings of milk (cups/day) -0.48 (-.82 to -.14) .006 1 Positive for perceived milk intolerance coded as 1, no perceived milk intolerance coded as 0. Thus 1 Positive for perceived lactose intolerance coded as 1, no perceived lactose intolerance coded negative is lower intake among PMI. Adjusted for location (state), race/ethnic group, weight, and as 0. Thus negative values indicate lower bone values among girls positive for PMI. Adjusted for age. location (state), race/ethnic group, BMI, Tanner score and age. Matlik et al. Pediatrics Sept 2007 Matlik et al. Pediatrics Sept 2007
Inclusion criteria Improving milk intake in milk- averse lactose digesters and • 18-55 years old maldigesters • Aversion to milk for at least 1 year • Only incidental consumption of milk for at Lauren O’Connor, Tracy K Eaton and Dennis A least 6 months Savaiano JNEB 47:4:325-330 Exclusion criteria Recruitment • Milk allergy • Chronic GI illness • Chronic heartburn • Stomach ulcers • Colon cancer • Gastroesophageal reflux disease • Pregnancy • Tobacco use • Antibiotic use within the past 2 months
Milk Introduction protocol Change in aversion and consumption Baseline 3 Month 6 Month Average Average p Average p Aversion Score 42.50 63.65 0.001 57.17 0.0345 (higher = less aversion) Likeness Score -1.62 -0.38 0.000 -0.48 0.000 (higher = like) Milk Consumption 0.31 10.23 0.000 5.91 0.000 (servings/month) BCAT Score* 18.23 32.65 0.000 26.96 0.0125 Symptom scores during HBT Milk Consumption Frequency at 3 Months Lactose Maldigesters during HBT* Digesters Maldigesters Total 0.35 Top milk 10 8 18 0.3 drinkers (>1 0.25 Symptom score average serving per 0.2 week) baseline 0.15 day 22 Bottom milk 5 3 8 drinkers (<1 0.1 serving per 0.05 week) 0 Total 15 11 26 -15 0 30 60 120 180 240 300 time (minutes) during hydrogen breath test
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