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The impact of lactose malabsorption and lactose intolerance on dairy consumption in children and adolescents with selected gastrointestinal diseases
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Available online at www.sciencedirect.com
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Original research article/Artykuł oryginalny
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The impact of lactose malabsorption and lactose intolerance on dairy consumption in children and adolescents with selected gastrointestinal diseases
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Wpływ nieprawidłowego trawienia i wchłaniania laktozy oraz nietolerancji laktozy na spożycie produktów mlecznych wśród dzieci i młodzieży z wybranymi chorobami przewodu pokarmowego
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Katarzyna Pawłowska 1,*, Wioleta Umławska 2, Barbara Iwańczak 1 1
2nd Department and Clinic of Pediatrics, Gastroenterology and Nutrition, Wroclaw Medical University, Wroclaw, Poland 2 Department of Human Biology, University of Wroclaw, Wroclaw, Poland
article info
abstract
Article history:
Background: Lactase deficiency may lead to gastrointestinal symptoms after milk inges-
Received: 21.02.2016
tion, known as lactose intolerance. Studies showed that lactose intolerant individuals avoid
Accepted: 23.03.2016
milk consumption, but they eat other dairy. Most of these studies were conducted on
Available online: xxx
healthy people. Aim: The aim of present study was to evaluate the impact of lactose malabsorption and lactose intolerance on dairy consumption in children with gastrointes-
Keywords: Dairy products
tinal diseases. Material and methods: Hydrogen breath test was conducted on pediatric
Gastrointestinal diseases Lactase
dairy products, flavored FDP, cheese and cottage cheese were collected. Differences in
Lactose intolerance Lactose malabsorption
patients aged from 2 to 19 years. Data regarding consumption of milk, plain fermented dairy consumption were analyzed between lactose absorbers and lactose malabsorbers, as well as between lactose intolerant and lactose tolerant individuals. Results: Two hundred and three children were selected to the study (82 males, mean age 11.39 years). There was no relationship between dairy products consumption and age. However, the frequency of
Słowa kluczowe: Produkty mleczne Choroby przewodu pokarmowego Laktaza
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Nietolerancja laktozy Zaburzenia trawienia i wchłaniania laktozy
lactose intolerance increased significantly with age. The type of gastrointestinal disease influenced only the cottage cheese consumption. Lactose intolerance decreased significantly milk consumption, but not other dairy products consumption. Lactose intolerants consumed dairy products (excluding milk) more often than lactose tolerants (38.2% and 23.6% respectively). Positive relationship between milk consumption and the consumption of FDP and cottage cheese was observed only in lactose absorbers and lactose tolerants. Conclusions: Lactose intolerance decreases milk consumption, but does not affect other
16 * Corresponding author at: Klinika Pediatrii, Gastroenterologii i Żywienia, Samodzielny Publiczny Szpital Kliniczny Nr 1, ul. M. CurieSkłodowskiej 50/52, 50-369 Wrocław, Poland. Tel.: +48 71 770 30 45; fax: +48 71 770 30 46. E-mail address: [email protected] (K. Pawłowska). http://dx.doi.org/10.1016/j.pepo.2016.03.013 0031-3939/© 2016 Published by Elsevier Sp. z o.o. on behalf of Polish Pediatric Society.
Please cite this article in press as: Pawłowska K, et al. The impact of lactose malabsorption and lactose intolerance on dairy consumption in children and adolescents with selected gastrointestinal diseases. Pediatr Pol. (2016), http://dx.doi.org/10.1016/j.pepo.2016.03.013
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dairy consumption. Dietary preferences play a key role in dairy consumption in lactose absorbers and lactose tolerant children. © 2016 Published by Elsevier Sp. z o.o. on behalf of Polish Pediatric Society.
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Introduction
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Milk is highly nutritional product considered a good source of essential amino acids and well-absorbed calcium. Adequate consumption of milk and other dairy products plays a key role in bone mineral density maintenance and may prevent obesity, type 2 diabetes, hypertension and metabolic syndrome [1, 2]. Low dairy consumption (and in consecutive calcium deficiency) in children contributes particularly to inadequate bone mineralization and poor growth [1, 3]. Milk and dairy avoidance may be a result of taste dislike or some adverse symptoms after its consumption [3, 4]. These symptoms may arise from cow milk protein allergy or lactose malabsorption [2]. Lactose is a milk disaccharide composed of glucose and galactose molecules. Under normal conditions, lactose is hydrolyzed in small intestine by the enzyme lactase (b-galactosidase) and absorbed as monosaccharides. Natural loss of lactase activity with age (primary lactase deficiency) or due to active gastrointestinal diseases, drugs or intestinal surgeries (secondary lactase deficiency) leads to lactose malabsorption. Undigested lactose enters the colon, where is fermented by colonic bacteria to gases (hydrogen, methane and carbon dioxide) and short-chain fatty acids. Excessive gas production may cause abdominal pain, cramping, bloating or vomiting, while high osmotic load in colon causes diarrhea. However, symptoms occurrence after lactose ingestion, called lactose intolerance, affects only a small number of people with lactose malabsorption. The occurrence of lactose intolerance depends on several factors, as lactose dose in relation to lactase activity, source of lactose and accompanying solid food, oro-cecal transit time, colonic microbiota action, colonic absorption capacity of lactose fermentation products, and individual visceral sensitivity [5–7]. Lactose malabsorption occurs in up to 30% of healthy children and adolescents in Poland, and its prevalence may rise above 50% in children with gastrointestinal diseases [8]. The combination of lactose malabsorption with gastrointestinal symptoms may decrease milk and other dairy products consumption in affected children [4, 9]. Usually one cup of milk or fermented dairy products (FDP), as yogurt or kefir, is well-tolerated by people with lactose malabsorption or lactose intolerance. Simultaneous milk consumption with solid foods brings the further decrease symptoms after lactose ingestion [10–12]. The possibility of colonic adaptation to lactose ingestion with no or negligible symptoms was also demonstrated [4, 13]. This suggests that many individuals with lactose malabsorption or lactose intolerance are able to receive appropriate amount of calcium with dairy products. The influence of lactose malabsorption and lactose intolerance has been already investigated. Many studies showed no difference in milk and other dairy products
consumption between lactose absorbers (LA) and lactose malabsorbers (LM) [6, 14]. However, lactose intolerance seemed to influence milk consumption [9]. Most of these studies were conducted on healthy individuals. Definitely less studies were conducted on patients with gastrointestinal diseases [15], where lactose intolerance may be one of the causes or the result of the disease [8, 16, 17]. The aim of present study was to determine milk and other dairy products consumption in relation to lactose absorption capacity and lactose tolerance in pediatric patients with selected gastrointestinal diseases.
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Material and methods
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Hydrogen breath test was conducted on pediatric patients, diagnosed and treated in II Department and Clinic of Pediatrics, Gastroenterology and Nutrition, in the years 2010–2013. Patients between 2 and 19 years of age with upper gastrointestinal tract diseases, lower gastrointestinal tract diseases and functional gastrointestinal disorders were selected to the study. Children with antibiotic treatment (during last month), chronic pulmonary diseases or milk protein allergy became excluded. Patients’ parents completed a questionnaire about the frequency of dairy products consumption during last month by their children. Products taken into account were milk, plain FDP, flavored FDP, cheese and cottage cheese. Dairy product was identified as “consumed” if the subject consumed it at least once a week; less than one customary portion of dairy product a week was identified as “not consumed”. One customary portion of each dairy product was determined as one glass of milk, kefir or buttermilk, one small package (150–200 g) of yogurt, one slice of cheese or half package (100 g) of cottage cheese. Based on the questionnaire, four dairy consumption patterns were distinguished: dairy-free diet (none dairy consumed), exclusive milk consumption (only milk consumed), other dairy consumption (at least one dairy product consumed, except milk) and milk and other dairy consumption (milk and at least one dairy product consumed). Hydrogen breath test was performed in the morning after overnight fast. Patients gave five breaths to the Gastro+ Gastrolyzer (Bedfont Scientific Ltd.). First breath was collected before test meal, and four subsequent breaths were given 15, 30, 60 and 90 min after test meal. The test meal was a lactose water solution, containing 30 g (up to 30 kg of patient's body mass) or 50 g (over 30 kg of patient's body mass) of this disaccharide in 250 mL of water. The increase in hydrogen in breath after lactose ingestion at least 20 ppm (parts per million), compared to the fasting breath, indicated a positive hydrogen breath test result. Patients with positive hydrogen breath test result were LM, while patients with negative result were LA. Gastrointestinal symptoms occurrence after lactose
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Please cite this article in press as: Pawłowska K, et al. The impact of lactose malabsorption and lactose intolerance on dairy consumption in children and adolescents with selected gastrointestinal diseases. Pediatr Pol. (2016), http://dx.doi.org/10.1016/j.pepo.2016.03.013
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ingestion was described as lactose intolerance. Lactose intolerants (LI) were lactose malaborbers with symptoms. Lactose tolerants (LT) were lactose absorbers and non-symptomatic lactose malabsorbers. Data were collected and analyzed using Statistica 10 software (STATSOFT, Inc.). As a preliminary analysis, differences in dairy consumption between each disease group were verified. The influence of age on dairy consumption was also tested. For this purpose, patients were divided into three age groups: 2–7.9 years of age, 8–12.9 years of age and over 13 years of age. In the next step, differences in each dairy product consumption and dairy consumption patterns were estimated between LM and LA and between LI and LT. The relation of milk consumption to each dairy product consumption was also tested for all absorption and tolerance groups. To perform all analyses, Person's x2 test or x2 test with Yates’ correction were used. Differences were considered significant at P value lower than 0.05. The study protocol was approved by Local Ethics Committee of Wroclaw Medical University. Informed consent for the study was obtained from patients’ caregivers and patients over 16 years of age.
Results
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The study involved 203 children (11.39 years, 82 males) with selected gastrointestinal diseases. Eighty-three subjects revealed upper gastrointestinal tract diseases (gastro-esophageal reflux disease or gastric/duodenal ulcer disease), 58 children had lower gastrointestinal tract diseases (celiac disease, secondary malabsorption syndrome or inflammatory bowel disease), and 64 children had functional gastrointestinal disorders (functional constipation or irritable bowel syndrome) (Table I). Lactose malabsorption was found in 74 subjects (36.4%) and the coexistence of lactose malabsorption and lactose intolerance was found in 55 subjects (27.1%). Lactose malabsorption tended to be most often in children and adolescents over 8 years of age, but only lactose intolerance frequency increased significantly with age (Table II). Preliminary analysis showed no differences in milk, plain FDP, flavored FDP and cheese consumption between disease groups. Only cottage cheese consumption differed between those groups. The highest frequency of cottage cheese
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Table I – Characteristics of subjects Tabela I – Charakterystyka badanych Diagnosis
Subjects n
Upper gastrointestinal tract diseases Gastro-oesophageal reflux disease Gastric/duodenal ulcers Lower gastrointestinal tract diseases Celiac disease/secondary malabsorption syndrome Inflammatory bowel disease Functional gastrointestinal disorders Functional constipation Irritable bowel syndrome Total
Mean age [years] (min–max)
82 37 45 57 33 24 64 45 19 203
11.53 10.54 12.35 11.62 9.79 14.14 11.00 9.58 14.35 11.39
(2.86–17.98) (2.86–17.98) (4.92–17.97) (2.50–18.48) (2.50–16.75) (8.59–18.48) (4.17–17.99) (4.17–17.55) (8.16–17.99) (2.50–18.48)
Males n (%) 30 18 12 28 16 12 24 15 9 82
(36.6%) (48.6%) (26.7%) (49.1%) (48.5%) (50.0%) (37.5%) (33.3%) (47.4%) (40.4%)
LM n (%) 24 15 9 29 18 11 21 12 9 74
(29.3%) (42.9%) (20.0%) (50.9%) (54.5%) (45.8%) (32.8%) (26.7%) (47.4%) (36.4%)
LI n (%) 18 12 6 19 11 8 18 10 8 55
(21.9%) (32.4%) (13.3%) (33.3%) (33.3%) (33.3%) (28.1%) (22.2%) (42.1%) (27.1%)
LM – lactose malabsorbers/pacjenci z zaburzeniem trawienia i wchłaniania laktozy; LI – lactose intolerants/pacjenci z nietolerancją laktozy.
Table II – Frequencies of lactose malabsorption, lactose intolerance and dairy products consumption according to age group (P value according to Pearson's x2 test) Tabela II – Częstość zaburzeń trawienia i wchłaniania laktozy, nietolerancji laktozy oraz spożycia produktów mlecznych w grupach wiekowych (wartość P na podstawie testu x2 Pearsona) Variable
LM LI Consumption of: Milk Plain FDP Flavored FDP Cheese Cottage cheese
Frequency in age groups, n (%)
P value
<8 years (n = 53)
8–12.9 years (n = 75)
13 years (n = 75)
12 (22.6%) 6 (11.3%)
31 (41.3%) 23 (30.7%)
31 (41.3%) 26 (34.7%)
0.05 0.009
35 22 45 35 31
53 34 56 58 52
49 42 57 63 54
0.76 0.22 0.35 0.06 0.25
(66.0%) (41.5%) (84.9%) (66.0%) (58.5%)
(70.7%) (45.3%) (74.7%) (77.3%) (69.3%)
(65.3%) (56.0%) (76.0%) (84.0%) (72.0%)
LM – lactose malabsorbers/pacjenci z zaburzeniem trawienia i wchłaniania laktozy; LI – lactose intolerants/pacjenci z nietolerancją laktozy; FDP – fermented dairy products/fermentowane produkty mleczne.
Please cite this article in press as: Pawłowska K, et al. The impact of lactose malabsorption and lactose intolerance on dairy consumption in children and adolescents with selected gastrointestinal diseases. Pediatr Pol. (2016), http://dx.doi.org/10.1016/j.pepo.2016.03.013
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Table III – Dairy products consumption according to lactose absorption capacity and lactose tolerance (P value according to x2 test with Yates’ correction) Tabela III – Spożycie produktów mlecznych w zależności od zdolności do trawienia i wchłaniania laktozy oraz tolerancji laktozy (wartość P na podstawie testu x2 z poprawką Yatesa) Dairy product
Consumers, n (%) LM (n = 74)
Milk Plain FDP Flavored FDP Cheese Cottage cheese
44 40 52 53 48
(59.5%) (54.0%) (70.3%) (71.6%) (64.9%)
P value
LA (n = 129) 93 58 106 103 89
(72.1%) (45.0%) (82.2%) (79.8%) (69.0%)
Consumers, n (%) LI (n = 55)
0.09 0.27 0.07 0.24 0.65
30 33 38 40 36
(54.5%) (60.0%) (69.1%) (72.7%) (64.4%)
P value
LT (n = 148) 107 65 120 116 101
(72.3%) (43.9%) (81.1%) (78.4%) (68.2%)
0.03 0.06 0.10 0.51 0.83
FDP – fermented dairy products/fermentowane produkty mleczne; LM – lactose malabsorbers/pacjenci z zaburzeniem trawienia i wchłaniania laktozy; LA – lactose absorbers/pacjenci z prawidłowym trawieniem i wchłanianiem laktozy; LI – lactose intolerants/pacjenci nietolerujący laktozę; LT – lactose tolerants/pacjenci nietolerujący laktozę.
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consumption was observed in children with upper gastrointestinal tract diseases, subsequently in children with functional gastrointestinal disorders, and the lowest consumption was in children with lower gastrointestinal tract diseases (78.0%, 67.2% and 52.6% respectively, P < 0.01). The frequency of milk and other dairy products consumption was similar in each age group (Table II). The frequency of milk and other dairy consumption did not differ between LM and LA. Lactose tolerance was the only factor influencing milk consumption in studied children. Lactose tolerant children consumed milk more often than LI. However, the consumption of the other dairy products was similar in both groups (Table III). Trends in dairy consumption patterns were similar in all studied groups. The consumption of milk with other dairy products was most frequent in each group. The least common patterns were dairy-free diet and exclusive milk consumption (5% and 1% respectively). Frequencies of two most common dairy consumption patterns differed between LI and LT. Lactose intolerants consumed dairy products without milk more often than LT (38.2% and 23.6% respectively), while LT consumed dairy with milk more often than LI (70.9% and 54.5% respectively), which was statistically significant (P = 0.049) (Fig. 1). Further analysis revealed that consumption of milk is positively associated with consumption of plain FDP and flavored FDP in LA (P < 0.001 and P = 0.002 respectively) and LT (P < 0.001 and P < 0.001 respectively) and with consumption of cottage cheese in LT (P = 0.04) (Fig. 2). In other groups, there was no relation of milk consumption to other dairy products consumption.
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Discussion
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Majority of studies on lactose malabsorption and lactose intolerance and its association with milk and other dairy consumption was carried out on healthy individuals [6, 9, 14]. Conversely, this study was focused on pediatric patients with selected gastrointestinal diseases and functional gastrointestinal disorders.
Fig. 1 – Frequencies of dairy consumption patterns in lactose malabsorbers (LM) and lactose absorbers (LA) (a), and lactose intolerant group (LI) and lactose tolerant group (LT) (b) (* P < 0.05 according to x2 test with Yates’ correction). Dairy consumption patterns were marked from A to D (A – dairy-free diet, B – exclusive milk consumption, C – other dairy consumption, D – milk and other dairy consumption) Ryc. 1 – Częstość występowania różnych wzorców spożycia produktów mlecznych u pacjentów z zaburzeniem trawienia i wchłaniania laktozy (LM) i prawidłowym trawieniem i wchłanianiem laktozy (LA) (a) oraz w grupach pacjentów nietolerujących laktozę (LI) i tolerujących laktozę (LT) (b) (* P < 0,05 na podstawie testu x2 z poprawką Yatesa). Wzorce spożycia produktów mlecznych zostały oznaczone od A do D (A – dieta bezmleczna, B – spożycie wyłącznie mleka, C – spożycie pozostałych produktów mlecznych, D – spożycie mleka i produktów mlecznych)
Please cite this article in press as: Pawłowska K, et al. The impact of lactose malabsorption and lactose intolerance on dairy consumption in children and adolescents with selected gastrointestinal diseases. Pediatr Pol. (2016), http://dx.doi.org/10.1016/j.pepo.2016.03.013
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Fig. 2 – The frequency of dairy products consumption (plain fermented dairy products (FDP), flavored FDP, cheese and cottage cheese) in milk consumers and non-consumers. Graphs present lactose absorbers (a) and lactose tolerant group (b) (* P < 0.05; ** P < 0.01; *** P < 0.001 according to x2 test with Yates’ correction) Ryc. 2 – Spożycie produktów mlecznych (naturalnych fermentowanych produktów mlecznych [FDP], dosładzanych FDP, serów dojrzewających i białych serów) wśród osób spożywających mleko i niespożywających mleka. Wykresy prezentują pacjentów bez zaburzeń trawienia i wchłaniania laktozy (a) oraz grupę pacjentów tolerujących laktozę (b) (* P < 0,05, ** P < 0,01, *** P < 0,001 na podstawie testu x2 z poprawką Yatesa)
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Patients with functional gastrointestinal disorders often have problems with identifying the cause of their ailments. It was found that children with recurrent abdominal pain declared symptoms after dairy consumption regardless of lactose absorption capacity [18]. Moreover, LA may overestimate their symptoms after milk consumption compared to symptoms after 50 g lactose challenge [19]. Wrong symptoms interpretation may be due to other nutrients intolerance, as fat or other carbohydrates (as fructose) contained in meal [19–21]. It was also demonstrated that fat contained in dairy products may exacerbate symptoms in Crohn patients regardless of lactose content [16]. On the other hand, patients with functional gastrointestinal disorders may be able to ignore their complaints after milk ingestion. It was shown that patients with functional dyspepsia more often declared symptoms after milk ingestion than healthy subjects (44% vs. 13%). Nevertheless, the frequency of regular milk ingestion did not differ between both groups [21]. In the present study, diagnosis did not influence milk and other dairy products consumption, except cottage
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cheese. The frequency of cottage cheese consumption was the highest in children with upper gastrointestinal tract diseases and the lowest in children with lower gastrointestinal tract diseases. Only one study compared dairy products consumption between children with various gastrointestinal diseases [15]. It was found that patients avoided regular milk drinking regardless of symptoms after its consumption. The highest milk consumption was observed in children with celiac disease and functional dyspepsia, whereas children with food allergy and irritable bowel syndrome avoided milk consumption most often. Dairy products as yogurt, kefir, cheese and cottage cheese were consumed most often without limitations in children with celiac disease, secondary malabsorption or functional gastrointestinal disorders [15]. Other study also showed that patients with inflammatory bowel disease often experienced the increase in symptoms severity after milk consumption, whereas symptoms after yogurt seemed to be improved [22]. Our study showed no differences in milk and other dairy products consumption between LA and LM. Similar results were obtained by other authors examining only healthy individuals [6, 9, 14]. Lactose malabsorption by itself has low impact on dairy consumption, as it is not always associated with gastrointestinal ailments. Present study indicated that only lactose malabsorption with symptoms decreased the consumption of milk. Study conducted among healthy individuals showed similar results. Symptomatic LM drank significantly less milk and received less daily calcium than others: asymptomatic LM and asymptomatic LA. However, cheese consumption was similar in all groups [9]. Nevertheless, it was found that many symptomatic LM were able to consume one cup of milk (12 g of lactose) with no or negligible symptoms. Further studies showed that even two cups of milk for two separate meals did not increase significantly gastrointestinal symptoms in self-reported LI [10]. Probably many lactose intolerance symptoms of mild to moderate severity may be trivialized by healthy individuals. However, our patients with gastrointestinal diseases might have enhanced symptoms after lactose compared to healthy persons, what discouraged them to milk consumption. It was shown that symptoms severity highly affected milk consumption frequency in healthy subjects [23]. The consumption of other dairy products did not differ between LM and LA, and between LI and LT. FDP, as yogurt and kefir, may be good source of calcium for LI individuals. Although these products contain lactose, breath hydrogen and methane excretion is lower after FDP consumption than after milk consumption. Symptoms after lactose ingestion in the form of FDP were also less severe than after the same dose of lactose contained in milk. Improved digestibility of FDP arises from the content of active bacterial b-galactosidase [11, 12, 24]. We also have observed that LI tended to be more willing to consume plain FDP and less willing to consume flavored FDP than LT. This can be explained that flavored FDP may induce or enhance gastrointestinal discomfort by the addition of fermentable saccharides and fruit [24]. The present study also indicated a high positive relationship between milk consumption and other dairy products consumption as plain and flavored FDP, but only in LA and LT groups. In these groups, milk consumers ate mentioned
Please cite this article in press as: Pawłowska K, et al. The impact of lactose malabsorption and lactose intolerance on dairy consumption in children and adolescents with selected gastrointestinal diseases. Pediatr Pol. (2016), http://dx.doi.org/10.1016/j.pepo.2016.03.013
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dairy products more often than milk non-consumers. In other groups we found no such strong food preferences. This suggests different dairy consumption habits, which depend on lactose absorption capacity and tolerance. Another study conducted in healthy children and youths showed that dietary habits. Dairy consumption was strongly associated with age, but not with lactose absorption capacity. However, there was no data about gastrointestinal symptoms after lactose ingestion [14]. In our study, age did not affect the consumption of any product. Our study focused on children and adolescents with frequently diagnosed gastrointestinal diseases and functional disorders. The influence of lactose absorption capacity and lactose tolerance was determined for milk and each dairy product as plain FDP, flavored FDP, cheese and cottage cheese. Beyond the determination of dairy consumption per se in each absorption and tolerance group, we also determined dietary patterns and the impact of eating habits on dairy consumption in studied groups. However, our study had some limitations. To evaluate lactose absorption capacity only hydrogen level was measured, while in some people intestinal microflora produce mainly or only methane. The use only hydrogen breath test might generate false negative test results in some of our subjects [11, 25]. However, it should be noted that excessive production of hydrogen, but not methane, is the main cause of gastrointestinal symptoms [26]. Therefore, we assume that individuals with highly methanogenic microflora should be able to consume milk and other dairy products with no or negligible complications. Second limitation were dosages of lactose we used (30 g or 50 g lactose dissolved in one cup of water). According to some authors, the dose of 50 g is not physiological and produces excessive symptoms in many LM. The usual dose of lactose (12 g), contained in dairy products, should not induce so disturbing symptoms [11]. Maybe if we had used lower dose of lactose (as 25 g in all subjects), the differences in dairy consumption between studied groups would have been more evident. However, the dose of 50 g of lactose is consistent with standard procedure and identifies lactose malabsorption in a short time [25]. In conclusion, present study showed that only lactose malabsorption with symptoms decreases milk consumption in children with gastrointestinal diseases. Therefore, fresh milk in those individuals should be replaced by other dairy products to prevent calcium deficiency. The role of food preferences in dairy consumption is evident only among LA and LT.
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Authors’ contributions/Wkład autorów
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KP – study design, data collection, statistical analysis, data interpretation, acceptance of final manuscript version, literature search. WU – statistical analysis, data interpretation, acceptance of final manuscript version. BI – study design, acceptance of final manuscript version.
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Conflict of interest/Konflikt interesu
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None declared.
Financial support/Finansowanie
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None declared.
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Ethics/Etyka
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The work described in this article have been carried out in accordance with The Code of Ethics of the World Medical Association (Declaration of Helsinki) for experiments involving humans; EU Directive 2010/63/EU for animal experiments; Uniform Requirements for manuscripts submitted to Biomedical journals.
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references/pi smiennictwo
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[15] Hutyra T, Iwańczak B. Ocena spoz˙ycia mleka oraz produktów mlecznych i jego zwiazku z upos´ledzonym trawieniem i wchłanianiem laktozy lub nietolerancja˛ laktozy w niektórych chorobach przewodu pokarmowego u dzieci. Pol Merk Lek 2009;26:110–116. [16] Nolan-Clark D, Tapsell LC, Hu R, Han DY, Ferguson LR. Effects of dairy products on Crohn's disease symptoms are influenced by fat content and disease location but not lactose content or disease activity status in a New Zealand population. J Am Diet Assoc 2011;111:1165–1172. [17] Ojetti V, Gabrielli M, Migneco A, Gasbarrini A. Regression of lactose malabsorption in coeliac patients after receiving a gluten-free diet. Scand J Gastroenterol 2008;43:174–177. [18] Webster RB, DiPalma JA, Gremse DA. Lactose maldigestion and recurrent abdominal pain in children. Dig Dis Sci 1995;40:1506–1510. [19] Casellas F, Aparici A, Casaus M, Rodríguez P, Malagelada JR. Subjective perception of lactose intolerance does not always indicate lactose malabsorption. Clin Gastroenterol Hepatol 2010;8:581–586. [20] Wilder-Smith CH, Materna A, Wermelinger C, Schuler J. Fructose and lactose intolerance and malabsorption testing: the relationship with symptoms in functional
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Please cite this article in press as: Pawłowska K, et al. The impact of lactose malabsorption and lactose intolerance on dairy consumption in children and adolescents with selected gastrointestinal diseases. Pediatr Pol. (2016), http://dx.doi.org/10.1016/j.pepo.2016.03.013
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Original research article/Artykuł oryginalny
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The impact of lactose malabsorption and lactose intolerance on dairy consumption in children and adolescents with selected gastrointestinal diseases
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Wpływ nieprawidłowego trawienia i wchłaniania laktozy oraz nietolerancji laktozy na spożycie produktów mlecznych wśród dzieci i młodzieży z wybranymi chorobami przewodu pokarmowego
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Katarzyna Pawłowska 1,*, Wioleta Umławska 2, Barbara Iwańczak 1 1
2nd Department and Clinic of Pediatrics, Gastroenterology and Nutrition, Wroclaw Medical University, Wroclaw, Poland 2 Department of Human Biology, University of Wroclaw, Wroclaw, Poland
article info
abstract
Article history:
Background: Lactase deficiency may lead to gastrointestinal symptoms after milk inges-
Received: 21.02.2016
tion, known as lactose intolerance. Studies showed that lactose intolerant individuals avoid
Accepted: 23.03.2016
milk consumption, but they eat other dairy. Most of these studies were conducted on
Available online: xxx
healthy people. Aim: The aim of present study was to evaluate the impact of lactose malabsorption and lactose intolerance on dairy consumption in children with gastrointes-
Keywords: Dairy products
tinal diseases. Material and methods: Hydrogen breath test was conducted on pediatric
Gastrointestinal diseases Lactase
dairy products, flavored FDP, cheese and cottage cheese were collected. Differences in
Lactose intolerance Lactose malabsorption
patients aged from 2 to 19 years. Data regarding consumption of milk, plain fermented dairy consumption were analyzed between lactose absorbers and lactose malabsorbers, as well as between lactose intolerant and lactose tolerant individuals. Results: Two hundred and three children were selected to the study (82 males, mean age 11.39 years). There was no relationship between dairy products consumption and age. However, the frequency of
Słowa kluczowe: Produkty mleczne Choroby przewodu pokarmowego Laktaza
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Nietolerancja laktozy Zaburzenia trawienia i wchłaniania laktozy
lactose intolerance increased significantly with age. The type of gastrointestinal disease influenced only the cottage cheese consumption. Lactose intolerance decreased significantly milk consumption, but not other dairy products consumption. Lactose intolerants consumed dairy products (excluding milk) more often than lactose tolerants (38.2% and 23.6% respectively). Positive relationship between milk consumption and the consumption of FDP and cottage cheese was observed only in lactose absorbers and lactose tolerants. Conclusions: Lactose intolerance decreases milk consumption, but does not affect other
16 * Corresponding author at: Klinika Pediatrii, Gastroenterologii i Żywienia, Samodzielny Publiczny Szpital Kliniczny Nr 1, ul. M. CurieSkłodowskiej 50/52, 50-369 Wrocław, Poland. Tel.: +48 71 770 30 45; fax: +48 71 770 30 46. E-mail address: [email protected] (K. Pawłowska). http://dx.doi.org/10.1016/j.pepo.2016.03.013 0031-3939/© 2016 Published by Elsevier Sp. z o.o. on behalf of Polish Pediatric Society.
Please cite this article in press as: Pawłowska K, et al. The impact of lactose malabsorption and lactose intolerance on dairy consumption in children and adolescents with selected gastrointestinal diseases. Pediatr Pol. (2016), http://dx.doi.org/10.1016/j.pepo.2016.03.013
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dairy consumption. Dietary preferences play a key role in dairy consumption in lactose absorbers and lactose tolerant children. © 2016 Published by Elsevier Sp. z o.o. on behalf of Polish Pediatric Society.
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Introduction
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Milk is highly nutritional product considered a good source of essential amino acids and well-absorbed calcium. Adequate consumption of milk and other dairy products plays a key role in bone mineral density maintenance and may prevent obesity, type 2 diabetes, hypertension and metabolic syndrome [1, 2]. Low dairy consumption (and in consecutive calcium deficiency) in children contributes particularly to inadequate bone mineralization and poor growth [1, 3]. Milk and dairy avoidance may be a result of taste dislike or some adverse symptoms after its consumption [3, 4]. These symptoms may arise from cow milk protein allergy or lactose malabsorption [2]. Lactose is a milk disaccharide composed of glucose and galactose molecules. Under normal conditions, lactose is hydrolyzed in small intestine by the enzyme lactase (b-galactosidase) and absorbed as monosaccharides. Natural loss of lactase activity with age (primary lactase deficiency) or due to active gastrointestinal diseases, drugs or intestinal surgeries (secondary lactase deficiency) leads to lactose malabsorption. Undigested lactose enters the colon, where is fermented by colonic bacteria to gases (hydrogen, methane and carbon dioxide) and short-chain fatty acids. Excessive gas production may cause abdominal pain, cramping, bloating or vomiting, while high osmotic load in colon causes diarrhea. However, symptoms occurrence after lactose ingestion, called lactose intolerance, affects only a small number of people with lactose malabsorption. The occurrence of lactose intolerance depends on several factors, as lactose dose in relation to lactase activity, source of lactose and accompanying solid food, oro-cecal transit time, colonic microbiota action, colonic absorption capacity of lactose fermentation products, and individual visceral sensitivity [5–7]. Lactose malabsorption occurs in up to 30% of healthy children and adolescents in Poland, and its prevalence may rise above 50% in children with gastrointestinal diseases [8]. The combination of lactose malabsorption with gastrointestinal symptoms may decrease milk and other dairy products consumption in affected children [4, 9]. Usually one cup of milk or fermented dairy products (FDP), as yogurt or kefir, is well-tolerated by people with lactose malabsorption or lactose intolerance. Simultaneous milk consumption with solid foods brings the further decrease symptoms after lactose ingestion [10–12]. The possibility of colonic adaptation to lactose ingestion with no or negligible symptoms was also demonstrated [4, 13]. This suggests that many individuals with lactose malabsorption or lactose intolerance are able to receive appropriate amount of calcium with dairy products. The influence of lactose malabsorption and lactose intolerance has been already investigated. Many studies showed no difference in milk and other dairy products
consumption between lactose absorbers (LA) and lactose malabsorbers (LM) [6, 14]. However, lactose intolerance seemed to influence milk consumption [9]. Most of these studies were conducted on healthy individuals. Definitely less studies were conducted on patients with gastrointestinal diseases [15], where lactose intolerance may be one of the causes or the result of the disease [8, 16, 17]. The aim of present study was to determine milk and other dairy products consumption in relation to lactose absorption capacity and lactose tolerance in pediatric patients with selected gastrointestinal diseases.
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Material and methods
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Hydrogen breath test was conducted on pediatric patients, diagnosed and treated in II Department and Clinic of Pediatrics, Gastroenterology and Nutrition, in the years 2010–2013. Patients between 2 and 19 years of age with upper gastrointestinal tract diseases, lower gastrointestinal tract diseases and functional gastrointestinal disorders were selected to the study. Children with antibiotic treatment (during last month), chronic pulmonary diseases or milk protein allergy became excluded. Patients’ parents completed a questionnaire about the frequency of dairy products consumption during last month by their children. Products taken into account were milk, plain FDP, flavored FDP, cheese and cottage cheese. Dairy product was identified as “consumed” if the subject consumed it at least once a week; less than one customary portion of dairy product a week was identified as “not consumed”. One customary portion of each dairy product was determined as one glass of milk, kefir or buttermilk, one small package (150–200 g) of yogurt, one slice of cheese or half package (100 g) of cottage cheese. Based on the questionnaire, four dairy consumption patterns were distinguished: dairy-free diet (none dairy consumed), exclusive milk consumption (only milk consumed), other dairy consumption (at least one dairy product consumed, except milk) and milk and other dairy consumption (milk and at least one dairy product consumed). Hydrogen breath test was performed in the morning after overnight fast. Patients gave five breaths to the Gastro+ Gastrolyzer (Bedfont Scientific Ltd.). First breath was collected before test meal, and four subsequent breaths were given 15, 30, 60 and 90 min after test meal. The test meal was a lactose water solution, containing 30 g (up to 30 kg of patient's body mass) or 50 g (over 30 kg of patient's body mass) of this disaccharide in 250 mL of water. The increase in hydrogen in breath after lactose ingestion at least 20 ppm (parts per million), compared to the fasting breath, indicated a positive hydrogen breath test result. Patients with positive hydrogen breath test result were LM, while patients with negative result were LA. Gastrointestinal symptoms occurrence after lactose
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Please cite this article in press as: Pawłowska K, et al. The impact of lactose malabsorption and lactose intolerance on dairy consumption in children and adolescents with selected gastrointestinal diseases. Pediatr Pol. (2016), http://dx.doi.org/10.1016/j.pepo.2016.03.013
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ingestion was described as lactose intolerance. Lactose intolerants (LI) were lactose malaborbers with symptoms. Lactose tolerants (LT) were lactose absorbers and non-symptomatic lactose malabsorbers. Data were collected and analyzed using Statistica 10 software (STATSOFT, Inc.). As a preliminary analysis, differences in dairy consumption between each disease group were verified. The influence of age on dairy consumption was also tested. For this purpose, patients were divided into three age groups: 2–7.9 years of age, 8–12.9 years of age and over 13 years of age. In the next step, differences in each dairy product consumption and dairy consumption patterns were estimated between LM and LA and between LI and LT. The relation of milk consumption to each dairy product consumption was also tested for all absorption and tolerance groups. To perform all analyses, Person's x2 test or x2 test with Yates’ correction were used. Differences were considered significant at P value lower than 0.05. The study protocol was approved by Local Ethics Committee of Wroclaw Medical University. Informed consent for the study was obtained from patients’ caregivers and patients over 16 years of age.
Results
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The study involved 203 children (11.39 years, 82 males) with selected gastrointestinal diseases. Eighty-three subjects revealed upper gastrointestinal tract diseases (gastro-esophageal reflux disease or gastric/duodenal ulcer disease), 58 children had lower gastrointestinal tract diseases (celiac disease, secondary malabsorption syndrome or inflammatory bowel disease), and 64 children had functional gastrointestinal disorders (functional constipation or irritable bowel syndrome) (Table I). Lactose malabsorption was found in 74 subjects (36.4%) and the coexistence of lactose malabsorption and lactose intolerance was found in 55 subjects (27.1%). Lactose malabsorption tended to be most often in children and adolescents over 8 years of age, but only lactose intolerance frequency increased significantly with age (Table II). Preliminary analysis showed no differences in milk, plain FDP, flavored FDP and cheese consumption between disease groups. Only cottage cheese consumption differed between those groups. The highest frequency of cottage cheese
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Table I – Characteristics of subjects Tabela I – Charakterystyka badanych Diagnosis
Subjects n
Upper gastrointestinal tract diseases Gastro-oesophageal reflux disease Gastric/duodenal ulcers Lower gastrointestinal tract diseases Celiac disease/secondary malabsorption syndrome Inflammatory bowel disease Functional gastrointestinal disorders Functional constipation Irritable bowel syndrome Total
Mean age [years] (min–max)
82 37 45 57 33 24 64 45 19 203
11.53 10.54 12.35 11.62 9.79 14.14 11.00 9.58 14.35 11.39
(2.86–17.98) (2.86–17.98) (4.92–17.97) (2.50–18.48) (2.50–16.75) (8.59–18.48) (4.17–17.99) (4.17–17.55) (8.16–17.99) (2.50–18.48)
Males n (%) 30 18 12 28 16 12 24 15 9 82
(36.6%) (48.6%) (26.7%) (49.1%) (48.5%) (50.0%) (37.5%) (33.3%) (47.4%) (40.4%)
LM n (%) 24 15 9 29 18 11 21 12 9 74
(29.3%) (42.9%) (20.0%) (50.9%) (54.5%) (45.8%) (32.8%) (26.7%) (47.4%) (36.4%)
LI n (%) 18 12 6 19 11 8 18 10 8 55
(21.9%) (32.4%) (13.3%) (33.3%) (33.3%) (33.3%) (28.1%) (22.2%) (42.1%) (27.1%)
LM – lactose malabsorbers/pacjenci z zaburzeniem trawienia i wchłaniania laktozy; LI – lactose intolerants/pacjenci z nietolerancją laktozy.
Table II – Frequencies of lactose malabsorption, lactose intolerance and dairy products consumption according to age group (P value according to Pearson's x2 test) Tabela II – Częstość zaburzeń trawienia i wchłaniania laktozy, nietolerancji laktozy oraz spożycia produktów mlecznych w grupach wiekowych (wartość P na podstawie testu x2 Pearsona) Variable
LM LI Consumption of: Milk Plain FDP Flavored FDP Cheese Cottage cheese
Frequency in age groups, n (%)
P value
<8 years (n = 53)
8–12.9 years (n = 75)
13 years (n = 75)
12 (22.6%) 6 (11.3%)
31 (41.3%) 23 (30.7%)
31 (41.3%) 26 (34.7%)
0.05 0.009
35 22 45 35 31
53 34 56 58 52
49 42 57 63 54
0.76 0.22 0.35 0.06 0.25
(66.0%) (41.5%) (84.9%) (66.0%) (58.5%)
(70.7%) (45.3%) (74.7%) (77.3%) (69.3%)
(65.3%) (56.0%) (76.0%) (84.0%) (72.0%)
LM – lactose malabsorbers/pacjenci z zaburzeniem trawienia i wchłaniania laktozy; LI – lactose intolerants/pacjenci z nietolerancją laktozy; FDP – fermented dairy products/fermentowane produkty mleczne.
Please cite this article in press as: Pawłowska K, et al. The impact of lactose malabsorption and lactose intolerance on dairy consumption in children and adolescents with selected gastrointestinal diseases. Pediatr Pol. (2016), http://dx.doi.org/10.1016/j.pepo.2016.03.013
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Table III – Dairy products consumption according to lactose absorption capacity and lactose tolerance (P value according to x2 test with Yates’ correction) Tabela III – Spożycie produktów mlecznych w zależności od zdolności do trawienia i wchłaniania laktozy oraz tolerancji laktozy (wartość P na podstawie testu x2 z poprawką Yatesa) Dairy product
Consumers, n (%) LM (n = 74)
Milk Plain FDP Flavored FDP Cheese Cottage cheese
44 40 52 53 48
(59.5%) (54.0%) (70.3%) (71.6%) (64.9%)
P value
LA (n = 129) 93 58 106 103 89
(72.1%) (45.0%) (82.2%) (79.8%) (69.0%)
Consumers, n (%) LI (n = 55)
0.09 0.27 0.07 0.24 0.65
30 33 38 40 36
(54.5%) (60.0%) (69.1%) (72.7%) (64.4%)
P value
LT (n = 148) 107 65 120 116 101
(72.3%) (43.9%) (81.1%) (78.4%) (68.2%)
0.03 0.06 0.10 0.51 0.83
FDP – fermented dairy products/fermentowane produkty mleczne; LM – lactose malabsorbers/pacjenci z zaburzeniem trawienia i wchłaniania laktozy; LA – lactose absorbers/pacjenci z prawidłowym trawieniem i wchłanianiem laktozy; LI – lactose intolerants/pacjenci nietolerujący laktozę; LT – lactose tolerants/pacjenci nietolerujący laktozę.
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consumption was observed in children with upper gastrointestinal tract diseases, subsequently in children with functional gastrointestinal disorders, and the lowest consumption was in children with lower gastrointestinal tract diseases (78.0%, 67.2% and 52.6% respectively, P < 0.01). The frequency of milk and other dairy products consumption was similar in each age group (Table II). The frequency of milk and other dairy consumption did not differ between LM and LA. Lactose tolerance was the only factor influencing milk consumption in studied children. Lactose tolerant children consumed milk more often than LI. However, the consumption of the other dairy products was similar in both groups (Table III). Trends in dairy consumption patterns were similar in all studied groups. The consumption of milk with other dairy products was most frequent in each group. The least common patterns were dairy-free diet and exclusive milk consumption (5% and 1% respectively). Frequencies of two most common dairy consumption patterns differed between LI and LT. Lactose intolerants consumed dairy products without milk more often than LT (38.2% and 23.6% respectively), while LT consumed dairy with milk more often than LI (70.9% and 54.5% respectively), which was statistically significant (P = 0.049) (Fig. 1). Further analysis revealed that consumption of milk is positively associated with consumption of plain FDP and flavored FDP in LA (P < 0.001 and P = 0.002 respectively) and LT (P < 0.001 and P < 0.001 respectively) and with consumption of cottage cheese in LT (P = 0.04) (Fig. 2). In other groups, there was no relation of milk consumption to other dairy products consumption.
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Discussion
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Majority of studies on lactose malabsorption and lactose intolerance and its association with milk and other dairy consumption was carried out on healthy individuals [6, 9, 14]. Conversely, this study was focused on pediatric patients with selected gastrointestinal diseases and functional gastrointestinal disorders.
Fig. 1 – Frequencies of dairy consumption patterns in lactose malabsorbers (LM) and lactose absorbers (LA) (a), and lactose intolerant group (LI) and lactose tolerant group (LT) (b) (* P < 0.05 according to x2 test with Yates’ correction). Dairy consumption patterns were marked from A to D (A – dairy-free diet, B – exclusive milk consumption, C – other dairy consumption, D – milk and other dairy consumption) Ryc. 1 – Częstość występowania różnych wzorców spożycia produktów mlecznych u pacjentów z zaburzeniem trawienia i wchłaniania laktozy (LM) i prawidłowym trawieniem i wchłanianiem laktozy (LA) (a) oraz w grupach pacjentów nietolerujących laktozę (LI) i tolerujących laktozę (LT) (b) (* P < 0,05 na podstawie testu x2 z poprawką Yatesa). Wzorce spożycia produktów mlecznych zostały oznaczone od A do D (A – dieta bezmleczna, B – spożycie wyłącznie mleka, C – spożycie pozostałych produktów mlecznych, D – spożycie mleka i produktów mlecznych)
Please cite this article in press as: Pawłowska K, et al. The impact of lactose malabsorption and lactose intolerance on dairy consumption in children and adolescents with selected gastrointestinal diseases. Pediatr Pol. (2016), http://dx.doi.org/10.1016/j.pepo.2016.03.013
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Fig. 2 – The frequency of dairy products consumption (plain fermented dairy products (FDP), flavored FDP, cheese and cottage cheese) in milk consumers and non-consumers. Graphs present lactose absorbers (a) and lactose tolerant group (b) (* P < 0.05; ** P < 0.01; *** P < 0.001 according to x2 test with Yates’ correction) Ryc. 2 – Spożycie produktów mlecznych (naturalnych fermentowanych produktów mlecznych [FDP], dosładzanych FDP, serów dojrzewających i białych serów) wśród osób spożywających mleko i niespożywających mleka. Wykresy prezentują pacjentów bez zaburzeń trawienia i wchłaniania laktozy (a) oraz grupę pacjentów tolerujących laktozę (b) (* P < 0,05, ** P < 0,01, *** P < 0,001 na podstawie testu x2 z poprawką Yatesa)
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Patients with functional gastrointestinal disorders often have problems with identifying the cause of their ailments. It was found that children with recurrent abdominal pain declared symptoms after dairy consumption regardless of lactose absorption capacity [18]. Moreover, LA may overestimate their symptoms after milk consumption compared to symptoms after 50 g lactose challenge [19]. Wrong symptoms interpretation may be due to other nutrients intolerance, as fat or other carbohydrates (as fructose) contained in meal [19–21]. It was also demonstrated that fat contained in dairy products may exacerbate symptoms in Crohn patients regardless of lactose content [16]. On the other hand, patients with functional gastrointestinal disorders may be able to ignore their complaints after milk ingestion. It was shown that patients with functional dyspepsia more often declared symptoms after milk ingestion than healthy subjects (44% vs. 13%). Nevertheless, the frequency of regular milk ingestion did not differ between both groups [21]. In the present study, diagnosis did not influence milk and other dairy products consumption, except cottage
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cheese. The frequency of cottage cheese consumption was the highest in children with upper gastrointestinal tract diseases and the lowest in children with lower gastrointestinal tract diseases. Only one study compared dairy products consumption between children with various gastrointestinal diseases [15]. It was found that patients avoided regular milk drinking regardless of symptoms after its consumption. The highest milk consumption was observed in children with celiac disease and functional dyspepsia, whereas children with food allergy and irritable bowel syndrome avoided milk consumption most often. Dairy products as yogurt, kefir, cheese and cottage cheese were consumed most often without limitations in children with celiac disease, secondary malabsorption or functional gastrointestinal disorders [15]. Other study also showed that patients with inflammatory bowel disease often experienced the increase in symptoms severity after milk consumption, whereas symptoms after yogurt seemed to be improved [22]. Our study showed no differences in milk and other dairy products consumption between LA and LM. Similar results were obtained by other authors examining only healthy individuals [6, 9, 14]. Lactose malabsorption by itself has low impact on dairy consumption, as it is not always associated with gastrointestinal ailments. Present study indicated that only lactose malabsorption with symptoms decreased the consumption of milk. Study conducted among healthy individuals showed similar results. Symptomatic LM drank significantly less milk and received less daily calcium than others: asymptomatic LM and asymptomatic LA. However, cheese consumption was similar in all groups [9]. Nevertheless, it was found that many symptomatic LM were able to consume one cup of milk (12 g of lactose) with no or negligible symptoms. Further studies showed that even two cups of milk for two separate meals did not increase significantly gastrointestinal symptoms in self-reported LI [10]. Probably many lactose intolerance symptoms of mild to moderate severity may be trivialized by healthy individuals. However, our patients with gastrointestinal diseases might have enhanced symptoms after lactose compared to healthy persons, what discouraged them to milk consumption. It was shown that symptoms severity highly affected milk consumption frequency in healthy subjects [23]. The consumption of other dairy products did not differ between LM and LA, and between LI and LT. FDP, as yogurt and kefir, may be good source of calcium for LI individuals. Although these products contain lactose, breath hydrogen and methane excretion is lower after FDP consumption than after milk consumption. Symptoms after lactose ingestion in the form of FDP were also less severe than after the same dose of lactose contained in milk. Improved digestibility of FDP arises from the content of active bacterial b-galactosidase [11, 12, 24]. We also have observed that LI tended to be more willing to consume plain FDP and less willing to consume flavored FDP than LT. This can be explained that flavored FDP may induce or enhance gastrointestinal discomfort by the addition of fermentable saccharides and fruit [24]. The present study also indicated a high positive relationship between milk consumption and other dairy products consumption as plain and flavored FDP, but only in LA and LT groups. In these groups, milk consumers ate mentioned
Please cite this article in press as: Pawłowska K, et al. The impact of lactose malabsorption and lactose intolerance on dairy consumption in children and adolescents with selected gastrointestinal diseases. Pediatr Pol. (2016), http://dx.doi.org/10.1016/j.pepo.2016.03.013
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dairy products more often than milk non-consumers. In other groups we found no such strong food preferences. This suggests different dairy consumption habits, which depend on lactose absorption capacity and tolerance. Another study conducted in healthy children and youths showed that dietary habits. Dairy consumption was strongly associated with age, but not with lactose absorption capacity. However, there was no data about gastrointestinal symptoms after lactose ingestion [14]. In our study, age did not affect the consumption of any product. Our study focused on children and adolescents with frequently diagnosed gastrointestinal diseases and functional disorders. The influence of lactose absorption capacity and lactose tolerance was determined for milk and each dairy product as plain FDP, flavored FDP, cheese and cottage cheese. Beyond the determination of dairy consumption per se in each absorption and tolerance group, we also determined dietary patterns and the impact of eating habits on dairy consumption in studied groups. However, our study had some limitations. To evaluate lactose absorption capacity only hydrogen level was measured, while in some people intestinal microflora produce mainly or only methane. The use only hydrogen breath test might generate false negative test results in some of our subjects [11, 25]. However, it should be noted that excessive production of hydrogen, but not methane, is the main cause of gastrointestinal symptoms [26]. Therefore, we assume that individuals with highly methanogenic microflora should be able to consume milk and other dairy products with no or negligible complications. Second limitation were dosages of lactose we used (30 g or 50 g lactose dissolved in one cup of water). According to some authors, the dose of 50 g is not physiological and produces excessive symptoms in many LM. The usual dose of lactose (12 g), contained in dairy products, should not induce so disturbing symptoms [11]. Maybe if we had used lower dose of lactose (as 25 g in all subjects), the differences in dairy consumption between studied groups would have been more evident. However, the dose of 50 g of lactose is consistent with standard procedure and identifies lactose malabsorption in a short time [25]. In conclusion, present study showed that only lactose malabsorption with symptoms decreases milk consumption in children with gastrointestinal diseases. Therefore, fresh milk in those individuals should be replaced by other dairy products to prevent calcium deficiency. The role of food preferences in dairy consumption is evident only among LA and LT.
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Authors’ contributions/Wkład autorów
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KP – study design, data collection, statistical analysis, data interpretation, acceptance of final manuscript version, literature search. WU – statistical analysis, data interpretation, acceptance of final manuscript version. BI – study design, acceptance of final manuscript version.
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Conflict of interest/Konflikt interesu
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None declared.
Financial support/Finansowanie
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None declared.
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Ethics/Etyka
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The work described in this article have been carried out in accordance with The Code of Ethics of the World Medical Association (Declaration of Helsinki) for experiments involving humans; EU Directive 2010/63/EU for animal experiments; Uniform Requirements for manuscripts submitted to Biomedical journals.
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