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Rapid Responses: Rapid Responses published:
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Lactose intolerance - dont forget the wheat!
- simon m greenfield (1 July 2007)
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Lactose intolerance
- JGB Russell, WA15 0ES (3 July 2007)
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Lactose malabsorption is rarely a clinical problem
- David A Gorard (5 July 2007)
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Re: Lactose intolerance
- Theo HM Fenton (6 July 2007)
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Cheese Doesn't Contain Lactose
- Laurie R Davis (6 July 2007)
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The treatment for lactose intolerance is staightforward - avoid lactose
- Philip Bickley (8 July 2007)
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BMJ reviewers and editors cought sleeping yet again
- Nikolai Manassiev (14 July 2007)
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Lactose intolerance: Is there a role for probiotics?
- Julian D Cespedes (16 July 2007)
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Hispanic origin?
- Philip Gampfer (1 May 2008)
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Some Say That No Adult Animals Other Than Humans Drink Milk
- Dr.Herbert H. Nehrlich (2 May 2008)
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Epidemiology of lactose intolerance
- Dr. Renata Adamek (30 March 2009)
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simon m greenfield, Consultant Gastroenterologist QE2 Hospital, Welwyn Garden City, Herts AL7 4HQ
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Dear Editor The article by Bhatnagar and Aggarwal provides a clear summary of the presentation and diagnosis of primary lactose intolerance. They briefly mention secondary causes of lactose intolerance and stress that this is often due to infection and indeed this is likely to be the case in India. However, they fail to mention coeliac disease as a secondary cause which is a serious omission given that it is common in the UK and Ireland (prevalence 1:300 and 1:100 respectively). General physicians in the UK need to be aware that patients presenting with symptoms typical of lactose intolerance are more likely to have coeliac disease than primary lactose intolerance. This can easily be confirmed by checking for tissue transglutaminase antibody. Once the diagnosis is confirmed by duodenal biopsy the patient can start a gluten free diet. As the small bowel heals milk can be safely reintroduced into the diet. Competing interests: None declared |
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JGB Russell, Retired Radiologist 96 Carrwood Hale Barns WA15 0ES, WA15 0ES
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The Authors omit two important facts in their review. First the sugar in human breast milk is the monosaccharide galactose. Thus in a wholly breat fed infant lactase deficiency is irrelevant. Second, as was noted, milk is a valuable food for all ages. The technologies for removing lactose from milk are ancient. They are cheesemaking and yogourt fermentation. JGB Russell
Competing interests: None declared |
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David A Gorard, Consultant Gastroenterologist Wycombe Hospital, Bucks, HP11 2TT
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Approximately 20% of North Europeans and Americans, and the majority of the world’s population malabsorb lactose, but most are asymptomatic. Lactose malabsorbers do get symptoms of lactose intolerance -abdominal cramps, bloating, flatulence and osmotic diarrhoea, if they ingest excessive amounts of lactose, such as in the lactose tolerance test which involves ingesting the lactose load (50g) found in 1 litre of cow’s milk, on an empty stomach. However lactose malabsorption is rarely a clinical problem in adults, since malabsorbers often recognise that excess dairy products cause upset and modify their diet spontaneously without the need for medical consultation. Furthermore, when lactose malabsorbers chronically ingest lactose, (colonic) bacterial adaptation occurs with increased tolerance for lactose [1]. The abdominal symptoms of lactose intolerance resemble those of irritable bowel syndrome. The prevalence of lactose malabsorption in irritable bowel syndrome is the same as in the general population [2]. Many irritable bowel syndrome patients either perceive themselves as lactose malabsorbers when they are not [2], or blame their coincident true lactose malabsorption for their symptoms despite evidence showing a poor symptomatic response to dietary lactose withdrawal [3-5]. Even lactose malabsorbers who consider themselves to be very lactose intolerant can actually tolerate moderately large amounts (12-24 g) of lactose (1-2 glasses milk) daily without symptoms [6]. Despite these data, possible lactose malabsorption is often frequently but futilely investigated in patients with irritable bowel syndrome. Patients with irritable bowel syndrome and coincident lactose malabsorption may make unnecessary efforts to avoid all lactose, including lactose used to make up pills. Such misapprehensions about the role of lactose in their symptom production are fuelled in some countries by a multi-million dollar industry promoting unnecessary lactase enzyme supplements and alternative milk products. ~ 1. Hertzler SR, Savaiano DA. Colonic adaptation to daily lactose feeding in lactose maldigesters reduces lactose intolerance. Am J Clin Nutr l996;64:232-36. 2. Vernia P, Marinaro V, Argnani F, Di Camillo M, Caprilli R. Self- reported milk intolerance in irritable bowel syndrome: what should we believe? Clin Nutr 2004; 23: 996-1000. 3. Suarez FL, Savaiano DA, Levitt MD. 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 1995;333:1-4. 4. Tolliver BA, Jackson MS, Jackson KL, Barnett ED, Chastang JF, DiPalma JA. Does lactose maldigestion really play a role in the irritable bowel? J Clin Gastroenterol 1996; 23: 15-7. 5. Parker TJ, Woolner JT, Prevost AT, Tuffnell Q, Shorthouse M, Hunter JO. Irritable bowel syndrome: is the search for lactose intolerance justified? Eur J Gastroenterol Hepatol 2001; 13: 219-25. 6. Suarez FL, Savaiano D, Arbisi P, Levitt MD. Tolerance to the daily ingestion of two cups of milk by individuals claiming lactose intolerance. Am J Clin Nutr 1997;65:1502-6. Competing interests: None declared |
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Theo HM Fenton, Consultant paediatrician Mayday Univeristy Hospital, Croydon CR7 7YE
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I was intrigued by Dr Russell's assertion that "the sugar in human breast milk is the monosaccharide galactose. Thus in a wholly breat fed infant lactase deficiency is irrelevant". The literature I can find does not seem to substantiate this. I quote from the first paragraph of VH Holsinger's chapter in Advanced Dairy Chemistry Volume 3, edited by PF Fox (Chapman & Hall 1997) (Page 1): "The California sea lion and other Pacific pinnipeds have no lactose in their milks... Milks of monotremes such as the echydna and platypus contain less than 0.1% lactose, while human milks contain one of the highest levels of lactose at 7%... bovine milks average 4.8%". The other references I can find seem to agree with the above, and it seems that galactose levels tend to be higher in cow's milk formulas than they are in breast milk (Cavalli C et al, J Pediatr Gastroenterol Nutr. 2006 Feb;42(2):215-221) Competing interests: None declared |
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Laurie R Davis, GP South Hermitage Surgery , South Hermitage, Shrewsbury sy3 7js
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Dear Sir , Your article contains a confusion when referring to the ability of people with lactose intolerance to tolerate cheese.It isn't necessary to invoke any mechanism ; common European cheeses do not contain any significant lactose.(1) Despite taking about 5 kilograms of milk to make 1 kilogram of Cheddar , the Cheddar contains the same amount of lactose as 2 grams of milk. So , with the exception of some of cottage cheese and some cheese spreads , they need not be avoided . Yours Sincerely, Laurie Davis Ref 1. The Composition of Foods , McCance & Widdowson , H.M.S.O. Competing interests: I eat cheese and drink milk |
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Philip Bickley, General Practice 190 Aston Lane, Handsworth, Birmingham, B20 3HE
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The recent article by Bhatnager and Aggarwal (1) highlighted the high levels of lactose intolerance that occur, particularly in Asian and Afro- Caribbean people. This can lead to distressing abdominal symptoms after ingestion of milk. Working in multi-cultural Birmingham I have been aware of this problem for some time and it has stimulated me to investigate the role of cow’s milk and its products in daily diets. I have found that current research questions the value of dairy consumption. The evidence for benefit of milk in children is lacking (2, 3) it has been suggested guidelines for calcium intake should be revised (4). Populations that consume the most cow's milk and other dairy products have among the highest rates of osteoporosis and hip fracture in later life (4). Studies have linked dairy consumption with prostate, testicular and ovarian cancer (5,6,7,8,9). Recently concern has been raised about dairy product consumption and a link to Parkinson’s disease (10) In addition to the above considerations I believe that people who give diet advice should consider if dairy consumption is contributing to a persons cardiovascular risk. The necessity of dairy in our diet is being questioned. Those who are lactose intolerant (and maybe those who are not) may be best advised to avoid lactose. (1) Bhatnager S, Aggarwal R. Lactose intolerance BMJ 2007;334:1331- 1332 (30 June) (2) Patient-Oriented Evidence that Matters BMJ 2005;331 (16 July) (3) Winzenberg T, Shaw K, Fryer J, Jones G. Effects of calcium supplementation on bone density in healthy children: meta-analysis of randomised controlled trials. BMJ 2006;333:775 (14 October) (4) Lanou A J. Bone health in children BMJ 2006;333:763-764 (14 October) (5) Chan JM, Stampfer MJ, Ma J, Gann PH, Gaziano JM, Giovannucci E. Dairy products, calcium, and prostate cancer risk in the physicians' health study. Am J Clin Nutr 2001;74: 549-54 (6) Gao X, LaValley MP, Tucker KL. Prospective Studies of Dairy Product and Calcium Intakes and Prostate Cancer Risk: A Meta-Analysis. J Natl Cancer Inst 2005 97(23):1768-1777 (7) Larsson SC, Bergkvist L, Wolk A. Milk and lactose intakes and ovarian cancer risk in the Swedish mammography cohort. Am J Clin Nutr 2004;80: 1353-7 (8) Genkinger JM, Hunter DJ, Spiegelman D, et al. Dairy products and ovarian cancer: a pooled analysis of 12 cohort studies. Cancer Epidemol Biomarkers Prev. 2006;15:364-72 (9) Stang A, Ahrens W, Baumgardt-Elms C, et al. Adolescent Milk Fat and Galactose Consumption and Testicular Germ Cell Cancer. Cancer Epidemiol Biomarkers Prev 2006;15(11):2189-2195 (10) Chen H, O’Reilly E, McCullough ML, Rodriguez C, et al. Consumption of Dairy Products and Risk of Parkinson’s Disease. Am J Epidemiol. 2007;165:998-1006. Competing interests: None declared |
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Nikolai Manassiev, GP 1 Goodrest Croft, Yardley Wood, Birmingham, B14 7DT
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Who reads the BMJ? The medical profession, student, lay people? What for? For education, research or simly for gossips? Whoever the readership is and whatever the reason for reading the BMJ is, one cannot expect them to read and reply to every single publication in the BMJ. Surely this is the role of the reviewers and editors. Sadly, not for a first, they have been asleep. Reading the first paragraph of this editorial, I realise that it is wildly wrong, not to say complete bonkers. Stating that lactose intolerance affects 'almost 100% of people in Asia and American Indians'defies common sense. Common sence tells us that 1) People in Asia include Russians, Mongolian, Chinese, Indians, Japanese, Arabs, Persians and many more, which have different genetic make-up, and it is rather implosible, ney imposible for all to have nearly 100 % lactose intolerance. And being fed on breast and cow's milk over the millenia, how come nobody noticed the 100 % lactose intolerance? The statement is not supported by science either, but it is waste of time for me go through the details. Why don't BMJ accept the error, appologise to the readers, tighted up the peer-review and editorial process? Competing interests: None declared |
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Julian D Cespedes, Primary Care Bogotá, Colombia
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Dear Sir
Lactose intolerance is definitely a common abdominal condition. There are many reports about the use of som lactobacilli to treat lactose intolerance with mixed results, mainly L. acidophilus and L.longum. Other studies mention the trophic effects on the intestinal mucosa after a short course with Saccharomyces boulardii. Is there any role for this approach, taking into account the cost-benefit relationship? Thanks Julián Céspedes 1. Gastroenterol Clin N Am 34 (2005) 515–532 2. Gastroenterol Clin N Am 34 (2005) 547–570 Competing interests: None declared |
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Philip Gampfer, biologist 7777 hispan
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What covers the specification of "people of hispanic origin"? People of Spain? Spanish-speaking people? In this case, what is the genetic relevance of a wide group of people which origin can be amerindian, african, and european of diverse origin? Thank you for your answer Competing interests: None declared |
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Dr.Herbert H. Nehrlich, Private Practice Bribie Island, Australia
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I wonder about lactose intolerance. Firstly, I have a suspicion that many cases of so-called lactose intolerance are in reality suffering from Irritable Bowel Syndrome. Since these symptoms tend to be intermittent and may flare up following idiosyncratic dietary transgressions, patients will be told, sooner or later, by a friend, the dairy manager of their supermarket or their busy GP that milk is the culprit and that they lack the enzyme lactase and thus join millions of others. I have personally seen many cases of diagnosed LI being able to tolerate raw cow's milk and had assumed for many years that homogenisation (Oster's disputed xanthine oxidase concept)or pasteurisation or perhaps the use of certain feedstuff for the cows were responsible. Hormones and antibiotics came to mind. Specially prepared lactose free milk did not seem to provide the answer for many, hence I am thinking that IBS may be far more common than LI in the European origin populations. Competing interests: None declared |
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Dr. Renata Adamek, Adjunct Department of Public Health, Poznan University of Medical Sciences, Poland
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We learned from the observational studies that lactose intolerance occurs in about 20-25% of people in western and central Europe. Till now, there was no such a need to perform countrywide observations that may show the regional differences in that. Some Polish studies on children showed that this special problems occurs in even 37% of persons (i.e. Socha P. 1999) and some others showed less than 17%. It should be assumed that lactose intolerance is very well defined, it differentiates regionally, although it is not well recognised in terms of nutritional epidemiology. It means that the phenomenon of lactose digestion and intolerance should be linked to nutritional customs of people from different countries or/and regions. Competing interests: None declared |
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