Lactose Intolerance: Health Authorities' Recommendations
Several authorities such as the National Institutes of Health, the American Academy of Pediatrics Committee on Nutrition, and the National Medical Association recommend that milk and milk products remain part of the diets of individuals with lactose intolerance
This overview of how to manage lactose intolerance focuses on the recommendations of national authorities such as the National Institutes of Health,1 the American Academy of Pediatrics Committee on Nutrition,2 and the National Medical Association.3
Health concerns of restricting the consumption of dairy products
Many individuals who perceive themselves to be lactose intolerant avoid dairy products. However, according to health authorities, it is not necessary for those with lactose intolerance to restrict their intake of dairy products or exclude them from their diets.1-4
Although restricting lactose intake may improve gastrointestinal symptoms, the long-term effects of a diet low in or free of dairy products are of nutritional concern.5 Restricting dairy intake deprives individuals of readily accessible sources of calcium, vitamin D and other key nutrients.1
Evidence indicates that children and adolescents who do not consume the recommended amounts of milk and milk products fail to meet their calcium requirements, which may prevent them from reaching peak bone mass. Insufficient dairy intake may also increase the risk for osteoporosis among older adults and has been linked to a higher risk of fractures.1,5
Moreover, milk and milk products have beneficial effects on different health outcomes, including a reduction of the risk of hypertension, colorectal cancer and diabetes. In a national multi-ethnic U.S. survey, higher rates of hypertension and diabetes were observed among individuals with self perceived lactose intolerance.6
Management strategies for lactose intolerance
Various management approaches have been shown to effectively alleviate the symptoms of lactose intolerance:
Ingesting limited amounts of lactose at a time
It is best to incorporate small amounts of milk or other lactose-containing foods in one's diet and space out intake throughout the day. Most studies show that individuals with lactose intolerance do not experience symptoms after ingesting small amounts of lactose-containing foods. In general, up to 12 grams of lactose (the equivalent of 1 cup of milk) in a single dose can be tolerated without significant symptoms, especially if taken with other foods.1 Most people with lactose intolerance, including children, can tolerate up to 2 cups of milk a day, divided into smaller quantities.2,4
Consuming milk and dairy products with other foods
Milk and dairy products are better tolerated if consumed with other foods or incorporated in a dish. The digestion of milk is slowed down when it is taken with a meal, resulting in a slower release of lactose in the small intestine, thereby reducing the lactose load to be digested at any one time.7
Ingestion with other solid foods, particularly those high in soluble fibre, also delays gastric emptying, which provides additional time for intestinal lactase to digest the lactose.2,4
Opting for dairy products such as yogurt, cheese and chocolate milk
Both yogurt and cheese are produced by the fermentation of milk by lactic acid bacteria. During this process, a certain quantity of lactose is converted to lactic acid. Therefore, yogurt is generally well tolerated, particularly those with active bacterial cultures, which help digest lactose.4,8 In addition, the semisolid state of yogurt slows gastric emptying and gastrointestinal transit, providing more time for lactose digestion.2,3
Some examples of cheeses that contain very little lactose are Mozzarella, Cheddar, Swiss, Brie and Blue (see table below).1,3
Chocolate milk also tends to be better tolerated than plain milk, although the reason is unclear.7
Preferring lactose-free and lactose-reduced milk and dairy products
In its Updated Consensus Statement, the National Medical Association reports that lactose free dairy products are the most ideal substitute for regular dairy products among individuals with lactose intolerance.3 In addition, evidence indicates that children prefer lactose-free cow’s milk over soy beverages.3
Furthermore, fortified beverages and other calcium-containing foods are not nutritionally equivalent replacements for cow’s milk. Incorporating such foods in one's diet may alter the overall dietary pattern, resulting in suboptimal intake of other key nutrients such as protein, magnesium, potassium, riboflavin and vitamin B12.3
Taking lactase enzyme pills
Oral lactase enzyme pills are another option to improve lactose digestion for those with lactose intolerance. It is recommended that the pills be taken with the first sip or bite of the dairy product.1,3
Colonic adaptation is a strategy where lactose intake is gradually increased over time.1 In some people, routine exposure to lactose can improve the efficiency of colonic bacteria to metabolize lactose, thus improving tolerance.4 One approach to build up tolerance is to take half a glass of milk with 1 meal on the first day, then with 2 meals, gradually increasing the frequency and quantity every day.7
Calcium and lactose content in common milk products9
|Milk product||Calcium content (mg)||Lactose content (g)|
|Whole milk, 1 cup||291||13.02|
|Partly skimmed milk, 2% M.F., 1 cup||302||12.92|
|Partly skimmed milk, 1% M.F., 1 cup||322||13.41|
|Skim milk, 1 cup||316||13.18|
|Cheddar cheese, 50 g||360||0.12|
|Emmenthal Swiss cheese, 50 g||396||0.03|
|Mozzarella cheese, 50 g||252||0.04|
|Parmesan cheese, 50 g||554||0.08|
Lactose intolerance, whether real or perceived, should not be a barrier to achieving a healthy diet.
Milk and milk products are nutritious foods that provide several essential nutrients such as calcium, vitamin D, magnesium, potassium and protein, and are associated with several health benefits including bone health and a reduced risk of hypertension, type 2 diabetes and colorectal cancer.
Among individuals with diagnosed lactose intolerance, various approaches can be employed to maintain milk and milk products as part of a healthy diet.
- Suchy FJ et al. NIH Consensus Development Conference Statement: lactose intolerance and health. NIH Consens State Sci Statements 2010;27:1-27.
- Heyman MB. Lactose intolerance in infants, children, and adolescents. Pediatrics 2006;118:1279-1286.
- Bailey RK et al. Lactose intolerance and health disparities among African Americans and Hispanic Americans: an updated consensus statement. J Natl Med Assoc 2013;105:112-127.
- Zaitlin P et al. Mistaken beliefs and the facts about milk and dairy foods. Nutr Today 2013;48:135-143.
- Misselwitz B et al. Lactose malabsorption and intolerance: pathogenesis, diagnosis and treatment. United European Gastroenterol J 2013;1:151-159.
- Nicklas TA et al. Self-perceived lactose intolerance results in lower intakes of calcium and dairy foods and is associated with hypertension and diabetes in adults. Am J Clin Nutr 2011;94:191-198.
- Heaney RP. Dairy intake, dietary adequacy, and lactose intolerance. Adv Nutr 2013;4:151-156.
- Rabot S et al. Guidance for substantiating the evidence for beneficial effects of probiotics: impact of probiotics on digestive system metabolism. J Nutr 2010;140:677S-689S.
- Health Canada. 2010. Canadian Nutrient File, version 2010. www.hc-sc.gc.ca. Accessed January 2, 2015.