© Valio Ltd May 16.2007 T. Tuure
Lactose intolerance:From the origin to treatment
Valio Ltd R&DTuula Tuure
© Valio Ltd May 16.2007 T. Tuure
What is lactose intolerance?
• Symptoms caused by maldigestionof lactose
Lactose is the carbohydrate (sugar) of milk
• Hypolactasia = Deficiency of lactaseLactase splits lactose in the intestine
© Valio Ltd May 16.2007 T. Tuure
Glukoosi
Glucose Galactose
Lactose
Glucose Galactose
Lactase enzyme
GalactoseGlucose
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Lactose in the intestine
Smallintestine
Largeintestine
Lactose tolerance Lactose intolerance
glucose
galactose
lactose
lactase Smallintestine
Largeintestine
lactose
lactaselactose
+bacteria
organicacids
+gas
+water
Symptoms
water
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What causes hypolactasia?• Genetic lactase deficiency
(Inborn lactase deficiency extremely rare)
•Intestinal diseases→ Damage of the intestinal villi→ Secondary lactase deficiency
• Lactase deficiency in prematureinfants
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surfac
e area for absorbtion.Picture 15. Villiincrease the
Courtesy of Dr Wagner, University of Delaware.
Lactase is found on the top of the intestinal villi
Blood vessels
Villus
Lactase
0,5 – 1 mm
© Valio Ltd May 16.2007 T. Tuure
TermsHypolactasia
Lactose maldigestion
Lactose-intolerance
+ lactose
Symptoms- Loose stools- Abdominalbloating and pain
- Gas problems
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Genetics of hypolactasia
• Mutation in the DNA found by a Finnishgroup of scientists(Enattah et al. Nature Genetics 2002;30:233-)
• C/T-13910 and T/T-13910 genotypesassociated with normolactasia
• C/C -13910 genotype is stronglyassociated with hypolactasia
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6
15 - 80
17
71
70
7370 90
9
9873
7560
83
90
13
24
54 - 37
40 - 70
Prevalence of primary lactose maldigestion
30-60
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Recent study carried out in Russiaon prevalences of hypolactasia
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Prevalences of hypolactasia in Russia
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Diagnostic methods• H2 Breath Test: bacteria in the bowel use lactose
generating hydrogen (H2) → detection of H2 in theexhaled air
• Lactose Tolerance Test: Lactose ingestion →detection of reduced or missing rise in blood glucose
• New tests• Detection of the heriditary primary hypolactasia with
genetic test system from blood or saliva
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Diagnostic methods: Pros and cons
No indication of intoleranceSecondary hypol. notdetected
No need for fastingFrom saliva: no need for blood sampleReliable for primaryhypolactasia
Gene test
Possibility for falsenegative results in certain cases
Good indication of intolerance
H2-test
ExaggeratessymptomsNot reliable in diabetes
Indication of intoleranceReadily available
Lactosetolerance test
DisadvantageAdvantageMethod
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Lactose intoleranceis not
milk allergy
© Valio Ltd May 16.2007 T. Tuure
Origin of the ailment
Enzymatic deficiency Immunologic reaction
Cause Lactose (carbohydrate)
Milk protein
Symptoms Flatulence, bloating, diarrhoea, abdominal pain
Exzema, nausea, diarrhoea, colic, respiratory dys-function, anaphylaxis
Occurrence Mainly in adults Almost exclusively in infants and small children
Lactose intolerance Milk allergy
Dietary treatment
Reduction of lactose Replacement of milk by special formulae
Differences of lactose intolerance and milk allergy
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At what age does lactosemaldigestion appear?
• High lactase activity after weaningException: congenital lactose maldigestion – very rare
• In lactose maldigesters lactase activity dropsto 1/10 by age 20 y
• Occationally the manifestation may continueafter age 20
• Sometimes symptoms appear only at later ageWeakened adaptive mechanisms of the intestines?
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Factors influencingthe symptoms
• Amount of lactose• Other indigestible carboh.• Other food• Gastric emptying and
gastrointestinal transit time• Intestinal, colonic microflora• Acidity of the intestine• Intestinal sensitivity
0102030405060708090
100
10 g 20 g 50 g
Persons with symptoms (%)
Amount of lactose(Sahi et al. 1983)
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Average content of lactose in different dairy products
< 0.02< 0.01Lactose-free milkand yoghurt
< 2< 1Low lactose milkand yoghurt
00Hard cheese
73.5Yoghurt
105Milk
Lactoseg/ 2 dl (portion)
Lactoseg/100 g
Product
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Treatment of lactose intoleranceTreatment Possible problemsLess dairy products Poorer diet
Deficiency of calciumLow-lactose products• Fermented• Lactose hydrolysed
Some lactose leftSweet taste in some products
Lactose-free products• Matured cheese• Removed lactose
-Methods not readily available
Lactase preparations• Added in the product• Consumed with the product
Sweet taste in some products, expensiveNot efficient in all individuals, expensive
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Calcium Intake of LactoseIntolerant Finnish Women (mg/d)
0100200300400500600700800900
1000
Women withLactoseIntoleranceAll Women
Recommendation
Honkanen et al., 1997
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© Valio Ltd May 16.2007 T. Tuure
Lactose-free products from Valio Ltd
Yoghurts
Milks and sour milks
Feta type cheeses
Creams
Set-type fermented dairy
Quark, Creme fraiche
© Valio Ltd May 16.2007 T. Tuure
What is lactose-free?
• No common definition• Lactose content may vary from 0,00 –
0,1 %• Sugar-free: < 0,5 %
Lactose is a sugar → lactose-free: < 0,5 % ???
• Best definition: < 0,01 %
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Low-lactose or lactose-free?
Lactose residue < 1% in hydrolysed low-lactose products
Lactose residue < 0,01% in lactose-free milk
Lactose-free milk by Valio
• no lactosesuitable for the mostsensible lactose intolerant
• 40% less carbohydrateslower calory content
• original, fresh milk taste
Low-lactose milk
• lactose content <1%may cause symptoms insome individuals
• Normal carbohydrate and calory content
• sweet taste
© Valio Ltd May 16.2007 T. Tuure
Conclusions
• 70 % of the world adult population havehypolactasia
• Feasible diagnostic methods are available• The majority tolerate small amounts of
lactose• The most sensitive need lactose-free
products• Savory low-lactose and lactose-free liquid
dairy products increase dairyconsumption