NIH Consensus Development Conference:
Lactose Intolerance
and Health
February 22–24, 2010
Bethesda, Maryland
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Background
Lactose intolerance is the inability to digest significant amounts of lactose, a sugar found in milk and other dairy products. Lactose intolerance is caused by a shortage of the enzyme lactase, which is produced by expression of lactase-phlorizin hydrolase gene by the cells that line the small intestine. Lactase breaks milk sugar down into two simpler forms of sugar called glucose and galactose, which are then absorbed into the bloodstream. Infants of every racial and ethnic group worldwide produce lactase and successfully digest lactose provided by human milk or by infant formulas. However, by the time many of the world’s children reach the age of 3-4 years, expression of intestinal lactase ceases. Most affected individuals, referred to as lactase nonpersisters, in the United States belong to minority groups, especially Asians, African Americans, Hispanics, Native Americans, Alaskan Natives, and Pacific Islanders.
Consumption of lactose-containing products by lactase nonpersisters may cause gas production, bloating, abdominal pain, and diarrhea. These symptoms of lactose intolerance are caused by intestinal bacteria’s fermentation of undigested lactose and often cause individuals to avoid lactose-containing products. Lactose intolerance can be diagnosed by drinking one to two large glasses of milk after fasting and measuring breath hydrogen levels a few hours later. Other diagnostic tools include analyzing an intestinal biopsy sample or determining the genetic makeup of the chromosomal region coding for lactase. However, many individuals mistakenly ascribe symptoms of a variety of intestinal disorders to lactose intolerance without undergoing testing. This becomes intergenerational when self-diagnosed lactose-intolerant parents place their children on lactose-restricted diets in the belief that the condition is hereditary.
Healthcare providers are concerned that many lactose-intolerant individuals are avoiding dairy products, which constitute a readily accessible source of calcium and are fortified with vitamin D and other nutrients. Therefore, these individuals may not be meeting recommended intakes of these essential nutrients. Insufficient intakes of calcium carry a risk of decreased bone mineral density. This may have effects on bone health and increase the risk of fracture throughout the lifecycle, especially in postmenopausal women. Very low intake of vitamin D can lead to the development of rickets, especially in those of African descent and other highly pigmented individuals. Although milk alternative products are typically fortified with vitamin D and other nutrients, they are often more expensive and less widely available than conventional products.
The public health burden from deficiencies attributable to lactose intolerance is difficult to quantify. Additionally, it is challenging to identify and manage lactase nonpersisters. Questions remain as to the amount, if any, of lactose that can be tolerated by lactose nonpersisters and how best to assist these individuals in meeting recommended intakes. To examine these important issues, the Eunice Kennedy Shriver National Institute of Child Health and Human Development and Office of Medical Applications of Research of the National Institutes of Health will convene a Consensus Development Conference from February 22 to 24, 2010 to assess the available scientific evidence related to the following questions:
- What is the prevalence of lactose intolerance, and how does this prevalence differ by race, ethnicity, and age?
- What are the health outcomes of dairy exclusion diets?
- What amount of daily lactose intake is tolerable in subjects with diagnosed lactose intolerance?
- What strategies are effective in managing individuals with diagnosed lactose intolerance?
- What are the future research needs for understanding and managing lactose intolerance?
Eunice Kennedy Shriver National Institute of Child Health and Human Development
Office of Medical Applications of Research
of the National Institutes of Health
Co-sponsors
Division of Nutrition Research Coordination
National Institute on Aging
National Institute of Diabetes and Digestive and Kidney Diseases
Office of Dietary Supplements
The Agency for Healthcare Research and Quality provided additional conference development support.
| 8:30 a.m. | Introduction and Opening Remarks Duane Alexander, M.D. Director Eunice Kennedy Shriver National Institute of Child Health and Human Development National Institutes of Health |
| 8:40 a.m. | Charge to the Panel Jennifer Miller Croswell, M.D. Acting Director Office of Medical Applications of Research Office of the Director National Institutes of Health |
| 8:50 a.m. | Conference Overview and Panel Activities Frederick J. Suchy, M.D. Panel and Conference Chairperson Herbert H. Lehman Professor and Chair The Jack and Lucy Clark Department of Pediatrics Mount Sinai School of Medicine of New York University Pediatrician-in-Chief, Mount Sinai Hospital |
| Overview of the Topic | |
| 9:00 a.m. | Early Feeding, Human Milk, and the Transition Josef Neu, M.D. Professor of Pediatrics Director of Neonatology Fellowship Training Program Division of Neonatology Department of Pediatrics College of Medicine University of Florida |
| 9:20 a.m. | Nutritive Value of Milk and Alternative Sources Nancy F. Krebs , M.D. Professor of Pediatrics and Head of Section of Nutrition Department of Pediatrics Center for Human Nutrition University of Colorado at Denver and Health Sciences Center |
| 9:40 a.m. | Cellular and Molecular Biology of Lactase Eric Sibley, M.D., Ph.D. Associate Professor Division of Pediatric Gastroenterology School of Medicine Stanford University |
| 10:00 a.m. | Discussion |
| 10:30 a.m. | What is Lactose Intolerance and How to Measure It Richard J. Grand, M.D. Professor of Pediatrics Harvard Medical School Program Director Clinical and Translational Study Unit Director, Center for Inflammatory Bowel Disease Children's Hospital |
| 10:50 a.m. | Clinical Presentation and Approach, But What if It Is Not Lactose Intolerance? Emeran A. Mayer, M.D. Professor Division of Digestive Disease/Gastroenterology Department of Medicine Executive Director Center for Neurobiology of Stress School of Medicine University of California |
| 11:10 a.m. | Discussion |
| I. | What is the Prevalence of Lactose Intolerance, and How Does This Prevalence Differ by Race, Ethnicity, and Age? |
| 11:30 a.m. | Population Genetics Sarah A. Tishkoff, Ph.D. Associate Professor Departments of Genetics and Biology David and Lyn Silfen University University of Pennsylvania |
| 11:50 a.m. | Ethnic Prevalence Wilma J. Wooten, M.D., M.P.H. President San Diego Chapter National Medical Association San Diego County Health Officer |
| 12:10 p.m. | Lunch Panel Executive Session |
| 1:10 p.m. | Aging: Lactose Intolerance and Calcium Absorption in the Elderly Richard J. Wood, Ph.D. Associate Professor Department of Nutrition Chenoweth Laboratories University of Massachusetts |
| 1:30 p.m. | Evidence-Based Practice Center Presentation I TBA |
| 1:50 p.m. | Discussion |
| II. | What are the Health Outcomes of Dairy Exclusion Diets? |
| 2:30 p.m. | Consequences of Excluding Dairy, Milk Avoiders, Calcium Requirements in Children Connie M. Weaver, Ph.D. Distinguished Professor and Head Foods and Nutrition Department College of Consumer and Family Sciences Purdue University |
| 2:50 p.m. | Consequences of Excluding Dairy, Milk Avoiders, Calcium
Requirements in Adults Robert P. Heaney, M.D., F.A.C.P., F.A.C.N. John A. Creighton University Professor Professor of Medicine Osteoporosis Research Center School of Medicine Creighton University |
| 3:10 p.m. | Evidence-Based Practice Center Presentation II TBA |
| 3:30 p.m. | Discussion |
| III. | What Amount of Daily Lactose Intake is Tolerable in Subjects with Diagnosed Lactose Intolerance? |
| 4:00 p.m. | Adaptation Andrew Szilagyi, M.D. McGill University School of Medicine Division of Gastroenterology Department of Medicine The Sir Mortimer B. Davis Jewish General Hospital |
| 4:20 p.m. | Dosing, Symptoms, Tolerable Doses of Lactose Dennis A. Savaiano, Ph.D. Professor and Dean College of Consumer and Family Science Department of Foods and Nutrition Purdue University |
| 4:40 p.m. | Evidence-Based Practice Center Presentation III TBA |
| 5:00 p.m. | Discussion |
| 5:30 p.m. | Adjournment |
Tuesday, February 23, 2010
| IV. | What Strategies are Effective in Managing Individuals with Diagnosed Lactose Intolerance? |
| 8:30 a.m. | Prebiotics David S. Newburg, Ph.D. Associate Professor of Pediatrics Harvard Medical School Director, Program in Glycobiology Pediatric Gastroenterology & Nutrition Massachusetts General Hospital |
| 8:50 a.m. | Probiotics Mary Ellen Sanders, Ph.D. Executive Director International Scientific Association for Probiotics and Prebiotics Consultant Dairy and Food Culture Technologies |
| 9:10 a.m. | Treatment Recommendations in Adults Jeanette Newton Keith, M.D. Associate Professor Department of Nutrition Sciences Department of Medicine University of Alabama-Birmingham |
| 9:30 a.m. | Treatment Recommendations in Children Catherine Gordon, M.D., M.Sc. Director, Children's Hospital Bone Health Program Adolescent / Young Adult Medicine and Endocrinology Division of Endocrinology Children’s Hospital Boston |
| 9:50 a.m. | Discussion |
| 10:30 a.m. | Evidence-Based Practice Center Presentation IV TBA |
| 10:50 a.m. | Behavioral Factors, Bone Consequences Susan Johnson, Ph.D. Associate Professor Department of Pediatrics, Section of Nutrition Health Sciences Center University of Colorado |
| 11:10 a.m. | Psychological Impacts Janet E. Taylor, M.D., M.P.H. Instructor in Clinical Psychiatry Department of Psychiatry Harlem Hospital Center Columbia University |
| 11:30 a.m. | Discussion |
| 12:00 p.m. | Adjournment |
Wednesday, February 24, 2010
| 9:00 a.m. | Presentation of the Draft Consensus Statement |
| 9:30 a.m. | Public Discussion |
| 11:00 a.m. | Adjournment Panel Meets in Executive Session |
| 2:00 p.m. | Press Telebriefing |
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