Lactose intolerance medical therapy: Difference between revisions

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__NOTOC__
__NOTOC__
{{Lactose intolerance}}
{{Lactose intolerance}}
{{CMG}}; {{AE}}{{MA}} [mailto:malihash@bidmc.harvard.edu] [mailto:malihash@bidmc.harvard.edu] [mailto:malihash@bidmc.harvard.edu] [mailto:malihash@bidmc.harvard.edu] [mailto:malihash@bidmc.harvard.edu] [mailto:malihash@bidmc.harvard.edu] [mailto:malihash@bidmc.harvard.edu] [mailto:malihash@bidmc.harvard.edu] [mailto:malihash@bidmc.harvard.edu] [mailto:malihash@bidmc.harvard.edu] [mailto:malihash@bidmc.harvard.edu] [mailto:malihash@bidmc.harvard.edu] [mailto:malihash@bidmc.harvard.edu] [mailto:malihash@bidmc.harvard.edu] [mailto:malihash@bidmc.harvard.edu] [mailto:malihash@bidmc.harvard.edu] [mailto:malihash@bidmc.harvard.edu]
{{CMG}}; {{AE}}{{MA}} [mailto:malihash@bidmc.harvard.edu]  
 
==Overview==
==Overview==
There is no treatment for [disease name]; the mainstay of therapy is supportive care.
OR
Supportive therapy for [disease name] includes [therapy 1], [therapy 2], and [therapy 3].
OR
The majority of cases of [disease name] are self-limited and require only supportive care.
OR
[Disease name] is a medical emergency and requires prompt treatment.
OR
The mainstay of treatment for [disease name] is [therapy].
OR
 
The optimal therapy for [malignancy name] depends on the stage at diagnosis.
OR
[Therapy] is recommended among all patients who develop [disease name].
OR
Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].
OR
Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].
OR


Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].
The mainstay of treatment for lactose intolerance is lifestyle modification that includes decreasing the consumption of dairy products or switcing to lactose-free or reduced [[lactose]] dairy products. Pharmacologic medical therapies for lactose intolerance include [[lactase]] enzyme preparations such as lactaid, lactogest, dairyease.
 
OR
 
Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].


==Medical Therapy==
==Medical Therapy==
*Pharmacologic medical therapy is recommended among patients with lactose intolerance that do not respond well to lifestyle modifications.  
*Pharmacologic medical therapy is recommended for patients with lactose intolerance who do not respond well to lifestyle modification.  
*Pharmacologic medical therapies for loctose intolerance include lactase enzyme preparations such as:<ref name="pmid6434367">{{cite journal |vauthors=Rosado JL, Solomons NW, Lisker R, Bourges H |title=Enzyme replacement therapy for primary adult lactase deficiency. Effective reduction of lactose malabsorption and milk intolerance by direct addition of beta-galactosidase to milk at mealtime |journal=Gastroenterology |volume=87 |issue=5 |pages=1072–82 |year=1984 |pmid=6434367 |doi= |url=}}</ref>
*Pharmacologic medical therapies for lactose intolerance include [[lactase]] enzyme preparations such as:<ref name="pmid6434367">{{cite journal |vauthors=Rosado JL, Solomons NW, Lisker R, Bourges H |title=Enzyme replacement therapy for primary adult lactase deficiency. Effective reduction of lactose malabsorption and milk intolerance by direct addition of beta-galactosidase to milk at mealtime |journal=Gastroenterology |volume=87 |issue=5 |pages=1072–82 |year=1984 |pmid=6434367 |doi= |url=}}</ref>
**Lactaid
**Lactaid
**Lactrase
**Lactogest
**DairyEase
**DairyEase
*Lactase enzyme preparations have bacterial or yeast beta-galactosidases
*Lactase enzyme preparations have bacterial or yeast beta-galactosidases
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=== Lifestyle modification ===
=== Lifestyle modification ===
* Patients with lactose intolerance are treated with dietary restriction of lactose and adequate intake of calcium. 
* Patients with lactose intolerance are treated with dietary restriction of [[lactose]] and adequate intake of calcium. <ref name="pmid26806042">{{cite journal |vauthors=Ianiro G, Pecere S, Giorgio V, Gasbarrini A, Cammarota G |title=Digestive Enzyme Supplementation in Gastrointestinal Diseases |journal=Curr. Drug Metab. |volume=17 |issue=2 |pages=187–93 |year=2016 |pmid=26806042 |pmc=4923703 |doi= |url=}}</ref><ref name="pmid22826639">{{cite journal |vauthors=Mattar R, de Campos Mazo DF, Carrilho FJ |title=Lactose intolerance: diagnosis, genetic, and clinical factors |journal=Clin Exp Gastroenterol |volume=5 |issue= |pages=113–21 |year=2012 |pmid=22826639 |pmc=3401057 |doi=10.2147/CEG.S32368 |url=}}</ref><ref name="pmid264043642">{{cite journal |vauthors=Silanikove N, Leitner G, Merin U |title=The Interrelationships between Lactose Intolerance and the Modern Dairy Industry: Global Perspectives in Evolutional and Historical Backgrounds |journal=Nutrients |volume=7 |issue=9 |pages=7312–31 |year=2015 |pmid=26404364 |pmc=4586535 |doi=10.3390/nu7095340 |url=}}</ref><ref name="pmid27882862">{{cite journal |vauthors=Thorning TK, Raben A, Tholstrup T, Soedamah-Muthu SS, Givens I, Astrup A |title=Milk and dairy products: good or bad for human health? An assessment of the totality of scientific evidence |journal=Food Nutr Res |volume=60 |issue= |pages=32527 |year=2016 |pmid=27882862 |pmc=5122229 |doi= |url=}}</ref>
** Milk and ice cream have highest amount of lactose, but due to high fat concentration and slower rate of gastric emptying rate in ice cream, compared to the milk, the symptoms of lactose intolerance with ingestion of ice cream is very mild.
** Milk and ice cream have highest amount of [[lactose]], but due to high fat concentration and slower rate of gastric emptying rate in ice cream compared to the milk, the symptoms of lactose intolerance with ingestion of ice cream is very mild.
** Levels of lactose is much lower in cheeses.
** Levels of lactose is much lower in cheese.


*One L of milk (equivalent to 50 grams of lactose) once a day, without any meals, usually cause symptoms in lactose intolerant persons.
*1 L of milk (equivalent to 50 grams of [[lactose]]) once a day, without any meals, usually cause symptoms in lactose intolerant persons.<ref name="pmid20404262">{{cite journal |vauthors=Shaukat A, Levitt MD, Taylor BC, MacDonald R, Shamliyan TA, Kane RL, Wilt TJ |title=Systematic review: effective management strategies for lactose intolerance |journal=Ann. Intern. Med. |volume=152 |issue=12 |pages=797–803 |year=2010 |pmid=20404262 |doi=10.7326/0003-4819-152-12-201006150-00241 |url=}}</ref>
*Limitation in lactose intake, the equivalent of 240 ml (8 oz, one cup) of milk or less a day cause less symptoms of lactose intolerance. <ref name="pmid7776987">{{cite journal |vauthors=Suarez FL, Savaiano DA, Levitt MD |title=A comparison of symptoms after the consumption of milk or lactose-hydrolyzed milk by people with self-reported severe lactose intolerance |journal=N. Engl. J. Med. |volume=333 |issue=1 |pages=1–4 |year=1995 |pmid=7776987 |doi=10.1056/NEJM199507063330101 |url=}}</ref>
*Limitation in lactose intake, the equivalent of 240 ml (8 oz, one cup) of milk or less a day causes less symptoms. <ref name="pmid7776987">{{cite journal |vauthors=Suarez FL, Savaiano DA, Levitt MD |title=A comparison of symptoms after the consumption of milk or lactose-hydrolyzed milk by people with self-reported severe lactose intolerance |journal=N. Engl. J. Med. |volume=333 |issue=1 |pages=1–4 |year=1995 |pmid=7776987 |doi=10.1056/NEJM199507063330101 |url=}}</ref>
*Two cups of milk per day, divided in two doses with food can be tolerated well. <ref name="pmid9129483">{{cite journal |vauthors=Suarez FL, Savaiano D, Arbisi P, Levitt MD |title=Tolerance to the daily ingestion of two cups of milk by individuals claiming lactose intolerance |journal=Am. J. Clin. Nutr. |volume=65 |issue=5 |pages=1502–6 |year=1997 |pmid=9129483 |doi= |url=}}</ref>  
*Two cups of milk per day, divided in two doses with food can be tolerated well. <ref name="pmid9129483">{{cite journal |vauthors=Suarez FL, Savaiano D, Arbisi P, Levitt MD |title=Tolerance to the daily ingestion of two cups of milk by individuals claiming lactose intolerance |journal=Am. J. Clin. Nutr. |volume=65 |issue=5 |pages=1502–6 |year=1997 |pmid=9129483 |doi= |url=}}</ref>  
*Patients with lactose intolerance are treated with dietary restriction of lactose and adequate intake of calcium. <ref name="pmid22826639">{{cite journal |vauthors=Mattar R, de Campos Mazo DF, Carrilho FJ |title=Lactose intolerance: diagnosis, genetic, and clinical factors |journal=Clin Exp Gastroenterol |volume=5 |issue= |pages=113–21 |year=2012 |pmid=22826639 |pmc=3401057 |doi=10.2147/CEG.S32368 |url=}}</ref><ref name="pmid264043642">{{cite journal |vauthors=Silanikove N, Leitner G, Merin U |title=The Interrelationships between Lactose Intolerance and the Modern Dairy Industry: Global Perspectives in Evolutional and Historical Backgrounds |journal=Nutrients |volume=7 |issue=9 |pages=7312–31 |year=2015 |pmid=26404364 |pmc=4586535 |doi=10.3390/nu7095340 |url=}}</ref>
*Yogurt containing live cultures which provides endogenous beta-galactosidase can be used as an alternative to milk products in patients with lactose intolerance. <ref name="pmid16482616">{{cite journal |vauthors=Montalto M, Curigliano V, Santoro L, Vastola M, Cammarota G, Manna R, Gasbarrini A, Gasbarrini G |title=Management and treatment of lactose malabsorption |journal=World J. Gastroenterol. |volume=12 |issue=2 |pages=187–91 |year=2006 |pmid=16482616 |pmc=4066025 |doi= |url=}}</ref>  
**Milk and ice cream have highest amount of lactose, but due to high fat concentration and slower rate of gastric emptying rate in ice cream, compared to the milk, the symptoms of lactose intolerance with ingestion of  ice cream is very mild.
*Attention to daily ingestion of [[calcium]] and [[vitamin D]] is necessary . Dietary [[calcium]] recommendation for adolescents and adults is 1200–1500 mg. [[Calcium]] and [[vitamin D]] supplementation should be considered if it is not enough in diet. <ref name="pmid22826639" />  
**Levels of lactose  is much lower in cheeses.
===Lactose intolerance===
*Yoghurt containing live cultures which provides endogenous beta-galactosidase can be used as an alternative to milk products in persons with lactose intolerant. <ref name="pmid16482616">{{cite journal |vauthors=Montalto M, Curigliano V, Santoro L, Vastola M, Cammarota G, Manna R, Gasbarrini A, Gasbarrini G |title=Management and treatment of lactose malabsorption |journal=World J. Gastroenterol. |volume=12 |issue=2 |pages=187–91 |year=2006 |pmid=16482616 |pmc=4066025 |doi= |url=}}</ref>  
'''Adult and pediatric'''
*In this regard, the available data58 demonstrate that a single dose of lactose (up to 12 g, equivalent to that contained in approximately one glass of milk) administered alone produces no or minor symptoms in persons with lactose intolerance or maldigestion. Lactose doses of 15–18 g are well tolerated when offered together with other nutrients. With doses larger than 18 g, intolerance becomes progressively more frequent, and quantities over 50 g elicit symptoms in most individuals.<ref name="pmid20404262">{{cite journal |vauthors=Shaukat A, Levitt MD, Taylor BC, MacDonald R, Shamliyan TA, Kane RL, Wilt TJ |title=Systematic review: effective management strategies for lactose intolerance |journal=Ann. Intern. Med. |volume=152 |issue=12 |pages=797–803 |year=2010 |pmid=20404262 |doi=10.7326/0003-4819-152-12-201006150-00241 |url=}}</ref>
* Lactaid (caplet), DairyEase (chewable tablet), Lactogest (soft gel capsule) : 3,000-9,000 units PO with meals or dairy<ref name="pmid6434367" /><ref name="pmid8223076">{{cite journal |vauthors=Lin MY, Dipalma JA, Martini MC, Gross CJ, Harlander SK, Savaiano DA |title=Comparative effects of exogenous lactase (beta-galactosidase) preparations on in vivo lactose digestion |journal=Dig. Dis. Sci. |volume=38 |issue=11 |pages=2022–7 |year=1993 |pmid=8223076 |doi= |url=}}</ref>    
*Whole milk and chocolate milk may be better tolerated than skim milk
* Lactaid drops:  5–15 drops in quart ( 946 ml ) of milk   
* There are many nondairy foods that contain calcium, including:
 
** Broccoli, okra, kale, collards, and turnip greens.
** Canned sardines, tuna, and salmon.
** Calcium-fortified juices and cereals.
** Calcium-fortified soy products such as soy milk, tofu, and soybeans.
** Almonds.
*'''1 Stage 1 - Name of stage'''<ref name="pmid64343672">{{cite journal |vauthors=Rosado JL, Solomons NW, Lisker R, Bourges H |title=Enzyme replacement therapy for primary adult lactase deficiency. Effective reduction of lactose malabsorption and milk intolerance by direct addition of beta-galactosidase to milk at mealtime |journal=Gastroenterology |volume=87 |issue=5 |pages=1072–82 |year=1984 |pmid=6434367 |doi= |url=}}</ref><ref name="pmid8223076">{{cite journal |vauthors=Lin MY, Dipalma JA, Martini MC, Gross CJ, Harlander SK, Savaiano DA |title=Comparative effects of exogenous lactase (beta-galactosidase) preparations on in vivo lactose digestion |journal=Dig. Dis. Sci. |volume=38 |issue=11 |pages=2022–7 |year=1993 |pmid=8223076 |doi= |url=}}</ref>
*
*, Lactogest (soft gel capsule), Lactaid (caplet), and DairyEase (chewable tablet
* Four capsules of Lactogest, two caplets of Lactaid, or two tablets of DairyEase (each treatment containing approx 6000 IU) reduced total hydrogen production significantly (P < 0.05) below that observed with two capsules of Lactogest (containing approx 3000 IU) in a stoichiometric manne
** 1.1 '''Specific Organ system involved 1'''
*** 1.1.1 '''Adult'''
**** Preferred regimen (1): [[drug name]] 100 mg PO q12h for 10-21 days '''(Contraindications/specific instructions)''' 
**** Preferred regimen (2): [[drug name]] 500 mg PO q8h for 14-21 days
**** Preferred regimen (3): [[drug name]] 500 mg q12h for 14-21 days
**** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days 
**** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
**** Alternative regimen (3): [[drug name]] 500 mg PO q6h for 14–21 days
*** 1.1.2 '''Pediatric'''
**** 1.1.2.1 (Specific population e.g. '''children < 8 years of age''')
***** Preferred regimen (1): [[drug name]] 50 mg/kg PO per day q8h (maximum, 500 mg per dose)  
***** Preferred regimen (2): [[drug name]] 30 mg/kg PO per day in 2 divided doses (maximum, 500 mg per dose)
***** Alternative regimen (1): [[drug name]]10 mg/kg PO q6h (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h (maximum, 500 mg per dose)
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h (maximum, 500 mg per dose)
****1.1.2.2 (Specific population e.g. '<nowiki/>'''''children < 8 years of age'''''')
***** Preferred regimen (1): [[drug name]] 4 mg/kg/day PO q12h（maximum, 100 mg per dose）
***** Alternative regimen (1): [[drug name]] 10 mg/kg PO q6h (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h (maximum, 500 mg per dose) 
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h (maximum, 500 mg per dose)
** 1.2 '''Specific Organ system involved 2'''
*** 1.2.1 '''Adult'''
**** Preferred regimen (1): [[drug name]] 500 mg PO q8h
*** 1.2.2  '''Pediatric'''
**** Preferred regimen (1): [[drug name]] 50 mg/kg/day PO q8h (maximum, 500 mg per dose)


* 2 '''Stage 2 - Name of stage'''
** 2.1 '''Specific Organ system involved 1 '''
**: '''Note (1):'''
**: '''Note (2)''':
**: '''Note (3):'''
*** 2.1.1 '''Adult'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 2 g IV q24h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 2 g IV q8h for 14 (14–21) days
***** Alternative regimen (2): [[drug name]] 18–24 MU/day IV q4h for 14 (14–21) days
**** Oral regimen
***** Preferred regimen (1): [[drug name]] 500 mg PO q8h for 14 (14–21) days
***** Preferred regimen (2): [[drug name]] 100 mg PO q12h for 14 (14–21) days
***** Preferred regimen (3): [[drug name]] 500 mg PO q12h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days 
***** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
***** Alternative regimen (3):[[drug name]] 500 mg PO q6h for 14–21 days
*** 2.1.2 '''Pediatric'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 50–75 mg/kg IV q24h for 14 (14–21) days (maximum, 2 g)
***** Alternative regimen (1): [[drug name]] 150–200 mg/kg/day IV q6–8h for 14 (14–21) days (maximum, 6 g per day)
***** Alternative regimen (2):  [[drug name]] 200,000–400,000 U/kg/day IV q4h for 14 (14–21) days (maximum, 18–24 million U per day) '<nowiki/>'''''(Contraindications/specific instructions)''''''
**** Oral regimen
***** Preferred regimen (1):  [[drug name]] 50 mg/kg/day PO q8h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Preferred regimen (2): [[drug name]] '''(for children aged ≥ 8 years)''' 4 mg/kg/day PO q12h for 14 (14–21) days (maximum, 100 mg per dose)
***** Preferred regimen (3): [[drug name]] 30 mg/kg/day PO q12h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Alternative regimen (1):  [[drug name]] 10 mg/kg PO q6h 7–10 days  (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h for 14–21 days  (maximum, 500 mg per dose)
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h for 14–21 days  (maximum,500 mg per dose)
** 2.2  '<nowiki/>'''''Other Organ system involved 2''''''
**: '''Note (1):'''
**: '''Note (2)''':
**: '''Note (3):'''
*** 2.2.1 '''Adult'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 2 g IV q24h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 2 g IV q8h for 14 (14–21) days
***** Alternative regimen (2): [[drug name]] 18–24 MU/day IV q4h for 14 (14–21) days
**** Oral regimen
***** Preferred regimen (1): [[drug name]] 500 mg PO q8h for 14 (14–21) days
***** Preferred regimen (2): [[drug name]] 100 mg PO q12h for 14 (14–21) days
***** Preferred regimen (3): [[drug name]] 500 mg PO q12h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days 
***** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
***** Alternative regimen (3):[[drug name]] 500 mg PO q6h for 14–21 days
*** 2.2.2 '''Pediatric'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 50–75 mg/kg IV q24h for 14 (14–21) days (maximum, 2 g)
***** Alternative regimen (1): [[drug name]] 150–200 mg/kg/day IV q6–8h for 14 (14–21) days (maximum, 6 g per day)
***** Alternative regimen (2):  [[drug name]] 200,000–400,000 U/kg/day IV q4h for 14 (14–21) days (maximum, 18–24 million U per day)
**** Oral regimen
***** Preferred regimen (1):  [[drug name]] 50 mg/kg/day PO q8h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Preferred regimen (2): [[drug name]] 4 mg/kg/day PO q12h for 14 (14–21) days (maximum, 100 mg per dose)
***** Preferred regimen (3): [[drug name]] 30 mg/kg/day PO q12h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Alternative regimen (1):  [[drug name]] 10 mg/kg PO q6h 7–10 days  (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h for 14–21 days  (maximum, 500 mg per dose)
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h for 14–21 days  (maximum,500 mg per dose)


==References==
==References==
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[[Category: (name of the system)]]
__NOTOC__
{{Lactose intolerance}}
{{CMG}}
==Overview==
Lactose intolerance is easy to treat. No treatment can improve the body’s ability to produce lactase, but symptoms can be controlled through [[diet]]. The basic principles involved in the management of lactose intolerance include avoiding dietary lactose, substitution of nutrients, using enzyme substitute and regulating calcium intake.
==Medical Therapy==
=== Managing Lactose Intolerance ===
For persons living in societies where the diet contains relatively little dairy, lactose intolerance is not considered a condition that requires treatment. However, those living among societies that are largely lactose-tolerant may find lactose intolerance troublesome. Although there are still no methodologies to reinstate lactase production, some individuals have reported their intolerance to vary over time (depending on health status and pregnancy<ref name:"Roy"> [http://www.emedicine.com/med/topic3429.htm ''Lactose Intolerance''. Roy, Barakat, Nwakakwa, Shojamanesh, Khurana, July 5, 2006] About 44% of lactose intolerant women regain the ability to digest lactose during pregnancy. This might be caused by slow intestinal transit and intestinal flora changes during pregnancy.<nowiki></ref></nowiki>). Lactose intolerance is not usually an all-or-nothing condition: the reduction in lactase production, and hence, the amount of lactose that can be tolerated varies from person to person. Since lactose intolerance poses no further threat to a person's health, managing the condition consists of minimizing the occurrence and severity of symptoms.
Berdanier and Hargrove recognize 4 general principals:
#Avoidance of dietary lactose
#Substitution to maintain nutrient intake
#Regulation of calcium intake
#Use of enzyme substitute
=== Avoiding Lactose-Containing Products ===
Since each individual's tolerance to lactose varies, according to the US [[National Institute of Health]], dietary control of lactose intolerance depends on people learning through trial and error how much lactose they can handle.<ref name="urlLactose Intolerance - National Digestive Diseases Information Clearinghouse">{{cite web |url=http://digestive.niddk.nih.gov/ddiseases/pubs/lactoseintolerance/ |title=Lactose Intolerance - National Digestive Diseases Information Clearinghouse |format= |work= |accessdate=2013-04-01}}</ref> Label reading is essential as commercial terminology varies according to language and region.<ref name="Berdanier">Berdanier, Hargrove, ''Nutrition and Gene Expression''.
CRC Press. 1993. ISBN 0849369614</ref>
Lactose is present in 2 large food categories: Conventional dairy products, and as a food additive (in dairy and non dairy products).
==== Dairy Products ====
Lactose is a water soluble molecule. In the curdling process lactose is found in the water portion along with whey and casein, but is not found in the fat portion. Therefore fat percentage and the curdling process have a certain impact on which foods may be tolerated. Conversely, low fat dairy foods often have various dairy derivatives such as milk solids added to them to enhance sweetness. Any dairy product which is fat reduced or fat free generally have a slightly higher lactose percentage.
* Milk: Human milk has the highest lactose percentage at around 9%. Unprocessed cow milk has 4.7% lactose. Unprocessed milk from other mammals contains similar lactose percentages (goat milk 4.1%,<ref>http://www.goatworld.com/articles/goatmilk/colostrum.shtml</ref> buffalo 4.86%,<ref name="Peeva">[http://bjas.hit.bg/07/693A.htm| Peeva. ''Composition of buffalo milk. Sources of specific effects on the separate components''. 2001. Bulg. J. Agric. Sci., 7: 329-335</ref> yak 4.93%,<ref>http://jag.igr.poznan.pl/2004-Volume-45/2/pdf/2004_Volume_45_2-215-224.pdf</ref> sheep milk 4.6% <ref>http://en.wikipedia.org/wiki/Goat_milk</ref>).
* Butter: The butter making process by definition separates milk's water components from the fat components. Lactose, being a water soluble molecule, will not be present in the butter unless milk solids are added to the ingredients.
* Yogurt and Kefir: People can be more tolerant of traditionally made yogurt than milk because it contains some lactase produced by the bacterial cultures used to make the yogurt. However, many commercial brands contain additional milk solids (lactose). Read labels.
* Cheeses: Traditionally made hard cheese (such as Swiss cheese) and soft ripened cheeses may create less reaction than the equivalent amount of milk because of the processes involved.  Fermentation and fat content contribute to lesser amounts of lactose. Traditionally made Swiss or Cheddar might contain 10% of the lactose found in whole milk. In addition, the traditional aging methods of cheese (over 2 yrs) reduces their lactose content to practically nothing.<ref name="urlI Love Cheese!, Cheese Guide, Good for You Cheese, Lactose Intolerance, FAQs">{{cite web |url=http://www.ilovecheese.com/lactose_intolerant_faqs.asp |title=I Love Cheese!, Cheese Guide, Good for You Cheese, Lactose Intolerance, FAQs |format= |work= |accessdate=2013-04-01}}</ref> Commercial cheese brands are generally manufactured by modern processes that do not have the same lactose reducing properties. Aged cheeses are usually aged for very short periods, and usually no laws mandate what qualifies as an aged cheese. One  must read labels carefully.
* Buttermilk, sour cream and ice cream, like yogurt, if made the traditional way, will generally be quite tolerable, but most modern brands add milk solids. <ref>[http://www.foodsci.uoguelph.ca/dairyedu/icform.html] University of Guelph, Dept. of Food Science, Dairy Science and Technology</ref> Consult labels. <ref>[http://jds.fass.org/cgi/content/abstract/34/2/136] Reger, Combs, Coulter and Koch. ''A Comparison of Dry Sweet Cream Buttermilk and Non-Fat Dry Milk Solids in Breadmaking''. Journal of Dairy Science Vol. 34 No. 2 136-144 </ref>
Examples of lactose levels in foods. As scientific consensus has not been reached concerning lactose percentage analysis methods <ref>[http://drinc.ucdavis.edu/goat1.htm Goat Milk Composition]</ref> (non-hydrated form or the mono-hydrated form), and considering that dairy content varies greatly according to labeling practices, geography and manufacturing processes, lactose numbers may not be very reliable. The following are examples of lactose levels in foods which commonly set off symptoms.<ref name="urlLactose Intolerance - National Digestive Diseases Information Clearinghouse">{{cite web |url=http://digestive.niddk.nih.gov/ddiseases/pubs/lactoseintolerance/ |title=Lactose Intolerance - National Digestive Diseases Information Clearinghouse |format= |work= |accessdate=2013-04-01}}</ref> These quantities are to be treated as guidelines only. Read the labels to be sure.
:{| border="1" cellspacing="0" cellpadding="5"
! Dairy product !!Lactose Content
|-
|Yogurt, plain, low-fat, 240 mL
| align="right" | 5 g&nbsp;&nbsp;
|-
|Milk, reduced fat, 240 mL
| align="right" | 11 g&nbsp;&nbsp;
|-
|Swiss cheese, 28 g
| align="right" | 1 g&nbsp;&nbsp;
|-
|Ice cream, 120 mL
| align="right" | 6 g&nbsp;&nbsp;
|-
|Cottage cheese, 120 mL
| align="right" | 2–3 g&nbsp;&nbsp;
|-
|}
==== Lactose in Non Dairy Products ====
Lactose (also present when labels state whey, milk solids, modified milk ingredients, etc) as a commercial food additive is used for its texture, flavor and adhesive qualities, and is found in foods such as processed meats (sausages/hot dogs, sliced meats, Pâtés), margarines,<ref>http://www.gov.ns.ca/JUST/REGULATIONS/regs/marge.htm Margarine Regulations</ref> sliced breads,<ref>[http://www.celiac.ca/Articles/PAB%20Enriching%20GF%20Foods.html] ''Enriched White Bread in Canada'' The Canadian Celiac Association </ref><ref>[http://jds.fass.org/cgi/content/abstract/29/12/821] ''Influence of Nonfat Dry Milk Solids on the Nutritive Value of Bread''. Journal of Dairy Science Vol. 29 No. 12 821-829</ref> breakfast cereals, potato chips,<ref name="Bartek">[http://www.bartek.ca/pdfs/Applications/SavouryProducts/SavourySnackFoods/Savoury%20Snack%20Foods%20Alphabetical%20List%20of%20Product%20Names.pdf] Bartek, food additive company]</ref> dried fruit, processed foods, medications, pre-prepared meals, meal replacement (powders and bars), protein supplements (powders and bars). 
Kosher products labeled ''pareve'' are mostly free of milk, however if a "D" is present next to the circled K, the food contains milk solids.<ref name="OHSU">[http://www.ohsu.edu/health/health-topics/topic.cfm?id=10182] ''General guidelines for milk allergy'', Oregon Health & Science University </ref>
==== Alternative Products ====
Milk:  The dairy industry has created quality low-lactose or lactose-free products to replace regular dairy. Lactose-free milk can be produced by passing milk over lactase enzyme bound to an inert carrier: once the molecule is cleaved, there are no lactose ill-effects. A form is available with reduced amounts of lactose (typically 30% of normal), and alternatively with almost 0%. Finland has had HYLA (acronym for ''hydrolysed lactose'') products available for many years, even though the number of lactose intolerant people there is relatively small.  These low-lactose level cow's milk products, ranging from ice cream to cheese, use a Valio patented chromatographic separation method to remove lactose. The ultra-pasteurization process, combined with aseptic packaging ensures a long shelf-life. Recently, the range of low-lactose products available in Finland has been augmented with milk and other dairy products (such as ice cream, butter, and buttermilk) that contain no lactose at all. The remaining about 20% of lactose in HYLA products is taken care of enzymatically. These typically cost 2 - 4 times  more than equivalent products containing lactose. Valio also markets these products in Sweden.
Plant based milks and derivatives are the only ones to be 100% lactose free (soy milk, almond milk, oat milk, rice milk, hemp milk, peanut milk). <ref>http://en.wikipedia.org/wiki/Plant_milk</ref>
Alternatively, bacterium such as ''L. acidophilus'' may be added, which affects the lactose in milk the same way it affects the lactose in yogurt.
=== Lactase Supplementation ===
When lactose avoidance is not possible, or on occasions when a person chooses to consume such items, then enzymatic [[lactase]] supplements may be used.<ref name="Montalto">{{cite journal | author = Montalto M, Curigliano V, Santoro L, Vastola M, Cammarota G, Manna R, Gasbarrini A, Gasbarrini G | title = Management and treatment of lactose malabsorption. | journal = World J Gastroenterol | volume = 12 | issue = 2 | pages = 187-91 | year = 2006 | id = PMID 16482616 | url=http://www.wjgnet.com/1007-9327/12/187.asp}}</ref><!--
  --><ref>{{cite journal | author = He M, Yang Y, Bian L, Cui H | title = [Effect of exogenous lactase on the absorption of lactose and its intolerance symptoms] | journal = Wei Sheng Yan Jiu | volume = 28 | issue = 5 | pages = 309-11 | year = 1999 | id = PMID 12712706}}</ref>
Lactase enzymes similar to the those produced in the small intestines of humans are produced industrially by [[fungi]] of the [[genus]] ''[[aspergillus]]''. The enzyme, β-galactosidase, is available in tablet form in a variety of doses, in many countries without a prescription. It functions well only in high-acid environments, such as that found in the human gut due to the addition of gastric juices from the stomach. Unfortunately, too much acid can denature it,<ref>{{cite journal | author = O'Connell S, Walsh G | title = Physicochemical characteristics of commercial lactases relevant to their application in the alleviation of lactose intolerance. | journal = Appl Biochem Biotechnol | volume = 134 | issue = 2 | pages = 179-91 | year = 2006 | id = PMID 16943638}}</ref> and it therefore should not be taken on an empty stomach. Also, the enzyme is ineffective if it does not reach the small intestine by the time the problematic food does. Lactose-sensitive individuals should experiment with both timing and dosage to fit their particular need. But supplements such as these may not be able to provide the accurate amount of [[lactase]] needed to adequately digest the [[lactose]] contained in dairy products, which may lead to symptoms similar to the existing lactose intolerance.
While essentially the same process as normal intestinal lactose digestion, direct treatment of milk employs a different variety of industrially produced lactase. This enzyme, produced by [[yeast]] from the genus ''[[kluyveromyces]]'', takes much longer to act, must be thoroughly mixed throughout the product, and is destroyed by even mildly acidic environments. It therefore has been much less popular as a consumer product (sold, where available, as a liquid) than the ''aspergillus''-produced tablets, despite its predictable effectiveness. Its main use is in producing the lactose-free or lactose-reduced dairy products sold in supermarkets.
Enzymatic lactase supplementation may have an advantage over avoiding dairy products, in that alternative provision does not need to be made to provide sufficient calcium intake, especially in children.<ref>{{cite journal | author = Heyman M | title = Lactose intolerance in infants, children, and adolescents. | journal = Pediatrics | volume = 118 | issue = 3 | pages = 1279–86 | year = 2006 | id = PMID 16951027 {{doi|10.1542/peds.2006-1721}} | url=http://pediatrics.aappublications.org/cgi/content/full/118/3/1279}}</ref>
=== Rehabituation to Dairy Products ===
For some people having secondary lactose intolerance and who are otherwise healthy, it may be possible to train bacteria in the large intestine to break down lactose more effectively<ref name="urlwww.agriculture.purdue.edu">{{cite web |url=http://www.agriculture.purdue.edu/agricultures/past/Spring1998/1998-Spring-Spotlights.pdf |title=www.agriculture.purdue.edu |format= |work= |accessdate=2013-04-01}}</ref> by consuming small quantities of dairy products several times a day over a couple of weeks. Adding dairy to diets of people who are sick may cause complications and even worsen the disease itself, especially if the dairy intake is not discovered in time as the real cause of the symptoms.
=== Nutritional Concerns ===
==== Primary Lactose Intolerance ====
Populations where primary lactose intolerance are the norm have demonstrated similar health levels to westerners.
==== Secondary Lactose Intolerance ====
While secondary lactose intolerance does not inherently affect an individual's nutritional needs,  according to mainstream media and accepted doctrines in western European and North American countries, dairy is an essential part of a healthy diet. Dairy products are relatively good and accessible sources of [[calcium]] and [[potassium]] and many contries mandate that milk be fortified with [[vitamin A]] and [[vitamin D]]. Consequently, in dairy consuming societies, dairy is often a main source of these nutrients; and, for lacto-vegetarians, a main source of [[vitamin B12]]. Individuals who reduce or eliminate consumption of dairy must obtain these nutrients elsewhere. Asian populations for whom dairy is not part of their food culture do not present with decreased health, and sometimes they present with above average health, like people in Japan.
Plant based milk substitutes are not naturally rich in calcium, potassium, or vitamins A or D (and, like all non-animal products, contain no vitamin B12). However, prominent brands are often voluntarily fortified with many of these nutrients; one should read the label to be certain.
An increasing number of calcium-fortified breakfast foods, such as orange juice, bread, and dry cereal, have been appearing on supermarket shelves. Many fruits and vegetables are rich in potassium and vitamin A; animal products like meat and eggs are rich in vitamin B12, and the human body itself produces some vitamin D from exposure to direct sunlight. Finally, a [[dietitian]] or physician may recommend a vitamin or mineral supplement to make up for any remaining nutritional shortfall.
Lactose reduced dairy products have the same nutritional content as their full-lactose counterparts, but their taste and appearance may differ slightly.
==== Congenital Lactase Deficiency ====
Before the 20th century, infants with this disease could not survive. Now parents need only supply lactose-free milk and dairy products and the child will then have the same nutritional concerns as people with secondary lactose intolerance.
==References==
{{Reflist|2}}
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[[Category:Gastroenterology]]
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Latest revision as of 22:28, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mahda Alihashemi M.D. [2] [3]

Overview

The mainstay of treatment for lactose intolerance is lifestyle modification that includes decreasing the consumption of dairy products or switcing to lactose-free or reduced lactose dairy products. Pharmacologic medical therapies for lactose intolerance include lactase enzyme preparations such as lactaid, lactogest, dairyease.

Medical Therapy

  • Pharmacologic medical therapy is recommended for patients with lactose intolerance who do not respond well to lifestyle modification.
  • Pharmacologic medical therapies for lactose intolerance include lactase enzyme preparations such as:[1]
    • Lactaid
    • Lactogest
    • DairyEase
  • Lactase enzyme preparations have bacterial or yeast beta-galactosidases
  • In secondary lactase deficiency, treatment is based on the underlying cause.

Lifestyle modification

  • Patients with lactose intolerance are treated with dietary restriction of lactose and adequate intake of calcium. [2][3][4][5]
    • Milk and ice cream have highest amount of lactose, but due to high fat concentration and slower rate of gastric emptying rate in ice cream compared to the milk, the symptoms of lactose intolerance with ingestion of ice cream is very mild.
    • Levels of lactose is much lower in cheese.
  • 1 L of milk (equivalent to 50 grams of lactose) once a day, without any meals, usually cause symptoms in lactose intolerant persons.[6]
  • Limitation in lactose intake, the equivalent of 240 ml (8 oz, one cup) of milk or less a day causes less symptoms. [7]
  • Two cups of milk per day, divided in two doses with food can be tolerated well. [8]
  • Yogurt containing live cultures which provides endogenous beta-galactosidase can be used as an alternative to milk products in patients with lactose intolerance. [9]
  • Attention to daily ingestion of calcium and vitamin D is necessary . Dietary calcium recommendation for adolescents and adults is 1200–1500 mg. Calcium and vitamin D supplementation should be considered if it is not enough in diet. [3]

Lactose intolerance

Adult and pediatric

  • Lactaid (caplet), DairyEase (chewable tablet), Lactogest (soft gel capsule) : 3,000-9,000 units PO with meals or dairy[1][10]
  • Lactaid drops: 5–15 drops in quart ( 946 ml ) of milk


References

  1. ↑ 1.0 1.1 Rosado JL, Solomons NW, Lisker R, Bourges H (1984). "Enzyme replacement therapy for primary adult lactase deficiency. Effective reduction of lactose malabsorption and milk intolerance by direct addition of beta-galactosidase to milk at mealtime". Gastroenterology. 87 (5): 1072–82. PMID 6434367.
  2. ↑ Ianiro G, Pecere S, Giorgio V, Gasbarrini A, Cammarota G (2016). "Digestive Enzyme Supplementation in Gastrointestinal Diseases". Curr. Drug Metab. 17 (2): 187–93. PMC 4923703. PMID 26806042.
  3. ↑ 3.0 3.1 Mattar R, de Campos Mazo DF, Carrilho FJ (2012). "Lactose intolerance: diagnosis, genetic, and clinical factors". Clin Exp Gastroenterol. 5: 113–21. doi:10.2147/CEG.S32368. PMC 3401057. PMID 22826639.
  4. ↑ Silanikove N, Leitner G, Merin U (2015). "The Interrelationships between Lactose Intolerance and the Modern Dairy Industry: Global Perspectives in Evolutional and Historical Backgrounds". Nutrients. 7 (9): 7312–31. doi:10.3390/nu7095340. PMC 4586535. PMID 26404364.
  5. ↑ Thorning TK, Raben A, Tholstrup T, Soedamah-Muthu SS, Givens I, Astrup A (2016). "Milk and dairy products: good or bad for human health? An assessment of the totality of scientific evidence". Food Nutr Res. 60: 32527. PMC 5122229. PMID 27882862.
  6. ↑ Shaukat A, Levitt MD, Taylor BC, MacDonald R, Shamliyan TA, Kane RL, Wilt TJ (2010). "Systematic review: effective management strategies for lactose intolerance". Ann. Intern. Med. 152 (12): 797–803. doi:10.7326/0003-4819-152-12-201006150-00241. PMID 20404262.
  7. ↑ Suarez FL, Savaiano DA, Levitt MD (1995). "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. 333 (1): 1–4. doi:10.1056/NEJM199507063330101. PMID 7776987.
  8. ↑ Suarez FL, Savaiano D, Arbisi P, Levitt MD (1997). "Tolerance to the daily ingestion of two cups of milk by individuals claiming lactose intolerance". Am. J. Clin. Nutr. 65 (5): 1502–6. PMID 9129483.
  9. ↑ Montalto M, Curigliano V, Santoro L, Vastola M, Cammarota G, Manna R, Gasbarrini A, Gasbarrini G (2006). "Management and treatment of lactose malabsorption". World J. Gastroenterol. 12 (2): 187–91. PMC 4066025. PMID 16482616.
  10. ↑ Lin MY, Dipalma JA, Martini MC, Gross CJ, Harlander SK, Savaiano DA (1993). "Comparative effects of exogenous lactase (beta-galactosidase) preparations on in vivo lactose digestion". Dig. Dis. Sci. 38 (11): 2022–7. PMID 8223076.

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