December 2015 Issue

Digestive Wellness: Lactose Intolerance and Nutrient Disparities
By Constance Brown-Riggs, MSEd, RD, CDE, CDN
Today's Dietitian
Vol. 17 No. 12 P. 16

Higher prevalence of chronic disease in minorities is linked with a lack of dairy food consumption.

Closing the nutrition disparities gap is key to improving overall population health. The 2015 Dietary Guidelines Advisory Committee (DGAC) stressed the need to address health disparities as a critical part of achieving a vision of health for all Americans.1 The 2015 DGAC found that vitamins A, D, E, and C; folate; calcium; magnesium; fiber; and potassium are nutrients that continue to be underconsumed by many Americans. Of these underconsumed nutrients, calcium, vitamin D, potassium, and fiber are classified as nutrients of public health concern. This is because their underconsumption is associated with adverse health outcomes such as overweight, obesity, diabetes, and cardiovascular disease, which disproportionately plague minority populations.1

The 2010 Dietary Guidelines for Americans (DGA) recommend three servings per day of low-fat and fat-free milk and milk products, such as yogurt and cheese, to help close the gap on calcium, vitamin D, and potassium.2 This advice—although well intentioned—often is culturally challenging for many black and Hispanic Americans who believe they're lactose intolerant.

Lactose intolerance, real or perceived, resulting in self-restriction of dairy foods has been identified by the National Institutes of Health as a public health problem.3 This article will discuss the impact of lactose intolerance on health disparities in minority populations, define lactose intolerance and lactose maldigestion, and provide strategies to help clients and patients close the nutrient intake gap and improve health equity.

Minority Health and Nutrients of Concern
The prevalence of obesity, diabetes, and heart disease is higher in minority populations than in white populations and has been linked to the underconsumption of dairy products. Specifically, from 2011 to 2012, the highest prevalence of obesity was among black American adults followed by Hispanic American adults.4 In 2011, the prevalence of diabetes among black American adults was nearly twice as high as that among white American adults,5 and the prevalence of heart disease was greatest in black Americans compared with Hispanic and white Americans. In addition, death rates from these diseases are higher among black Americans. For example, in 2013, death rates from heart disease were highest among black Americans compared with other racial populations,6 and black Americans are twice as likely to die from diabetes complications.6

Health disparities also exist in population access to affordable healthful foods, with low-income populations bearing a greater burden (see Table).

Lactose Intolerance vs Lactose Maldigestion
Lactose is a naturally occurring sugar found in yogurt and other milk products. During digestion, an intestinal enzyme called lactase breaks down lactose into two smaller, more easily digested sugars: glucose and galactose.

Lactose intolerance often is misunderstood. It's a condition in which people have gastrointestinal disturbances—such as bloating, diarrhea, and gas—after eating or drinking milk or milk products. Barbara Baron, RDN, owner of Barbara Baron Associates in Old Bridge, New Jersey, and known as The Family Meals Dietitian says, "the gastrointestinal disturbances occur after eating an amount of lactose that's greater than the body's ability to digest and absorb. When not digested, the healthy bacteria ferment the lactose in the intestinal tract. This fermentation produces uncomfortable symptoms such as gas, stomach pain, or bloating."

Lactose maldigestion is the incomplete digestion of lactose due to a lactase deficiency. "However, not everyone with low lactase is lactose intolerant," Baron says. "Some people with lower lactase levels may not experience the digestive discomfort when they consume milk or milk products. For example, an individual with lactose maldigestion may consume 12 g of lactose—the amount of lactose in one cup of milk without symptoms, but be intolerant to 24 g, which is the amount in two cups of milk."

Yogurt and Lactose Intolerance
According to the 2010 DGA, evidence shows that the intake of milk and milk products is associated with a reduced risk of cardiovascular disease, type 2 diabetes, and high blood pressure in adults—disease states that affect black and Hispanic Americans at disproportionate rates.1

Unfortunately, many black and Hispanic Americans are missing out on the health benefits of dairy because they believe they're lactose intolerant. Angela Lemond, RDN, CSP, LD, spokesperson for the Academy of Nutrition and Dietetics, finds this to be the case with many of her patients. She says perceived lactose intolerance can be generational. "If their grandparents and parents never ate dairy and the family has always kept dairy out of their diet, the patient assumes they can't tolerate it." In fact, current research shows that nearly 20% of black Americans and 10% of Hispanic Americans consider themselves lactose intolerant.7

Yogurt can help these individuals with lactose intolerance meet their dairy requirements and obtain critical nutrients of concern. Lemond, who's lactose intolerant, says, "I notice when I drink a glass of milk I have symptoms, but yogurt doesn't bother me." Yogurt is a more easily digestible alternative to milk, because of the presence of lactase-producing yogurt cultures, and on average yogurt contains less lactose per serving than milk.8

Research shows that yogurt not only is nutrient dense but also can address income-related disparities in diet quality, as evidenced in the WIC pilot study published in the May-June 2010 issue of the Journal of Nutrition Education and Behavior. The study was conducted in response to the Institute of Medicine (IOM) of the National Academies' report "WIC Food Packages: Time for a Change," identifying the need for WIC to address the nutritional needs of individuals who avoid milk due to cultural food preferences or lactose maldigestion. In the report, the IOM recommended yogurt be added as a substitute for part of the WIC participants milk allowance. To address this recommendation, the USDA, which manages WIC, first needed to determine the cost implications of adding yogurt and whether WIC participants would accept yogurt.9

The study concluded that yogurt was a popular substitute for milk that provided an option for the dietary needs of WIC participants who were either lactose intolerant or irregular milk drinkers. Adding yogurt also removed participants' perceived cost barrier and addressed income-related disparities that affect diet quality.10 These positive results from the WIC pilot study were instrumental in the approval of yogurt as a low-lactose substitution for milk, and it was added to the revised WIC food packages, effective April 2015.9

Closing the Nutrient Intake Gap
In their joint 2013 consensus statement on lactose intolerance, The National Medical Association and the National Hispanic Medical Association recommend three servings of low-fat dairy per day as a means of closing the nutrient intake gap. Moreover, the consensus statement encourages health care providers to help patients with real or perceived lactose intolerance employ strategies to achieve the recommended dairy food intake levels.

Baron offers the following strategies:
• For patients who experience gastrointestinal discomfort from milk, recommend they start with about 4 oz of milk and drink it with a meal. This helps to slow down and improve the digestion of lactose.

• Suggest clients make soups, pancakes, and oatmeal with lactose-free milk or yogurt. On average, yogurt contains less lactose than milk, making it a more easily digested dairy option.

• Recommend hard cheeses like Swiss and cheddar. They're low in lactose and excellent sources of calcium and protein.

• Encourage patients to explore the dairy aisle in the supermarket. There are many choices of milk, cheese, and yogurt they can purchase that will help them meet their dairy requirements.

Employing these strategies can help minorities receive all the heath benefits of dairy and support health equity in these populations.

— Constance Brown-Riggs, MSEd, RD, CDE, CDN, is nutrition advisor for the Dannon One Yogurt Every Day Initiative; a past national spokesperson for the Academy of Nutrition and Dietetics, specializing in African American nutrition; and author of The African American Guide to Living Well With Diabetes and Eating Soulfully and Healthfully With Diabetes.

1. US Office of Disease Prevention and Health Promotion, US Office of the Assistant Secretary for Health, US Office of the Secretary, and US Department of Health and Human Services. Scientific Report of the 2015 Dietary Guidelines Advisory Committee: part D p3 - appendix E-3.6. Published February 2015. Accessed August 12, 2015.

2. US Department of Agriculture and US Department of Health and Human Services. Dietary Guidelines for Americans, 2010. 7th ed. Published December 2010. Accessed August 14, 2015.

3. Wilt TJ, Shaukat A, Shamiliyan T, et al. Lactose intolerance and health. Evid Rep Technol Assess (Full Rep). 2010:192:1-410.

4. Schiller JS, Lucas JW, Peregoy JA. Summary health statistics for US adults: National Health Interview Survey, 2011. National Center for Health Statistics. Vital Health Stat. 10(256). Published December 2012. Accessed August 12, 2015.

5. Heart disease and African Americans. US Department of Health and Human Services Office of Minority Health website. Updated October 8, 2015. Accessed October 12, 2015.

6. Diabetes and African Americans. US Department of Health and Human Services Office of Minority Health website. Updated June 16, 2015. Accessed October 12, 2015

7. Savaiano DA, Boushey CJ, McCabe GP. Lactose intolerance symptoms assessed by meta-analysis: a grain of truth that leads to exaggeration. J Nutr. 2006;136(5):1107-1113. 

8. US Department of Agriculture. National Nutrient Database for Standard Reference Release 26. Accessed October 12, 2015. 

9. Women, Infants and Children (WIC) final rule: revisions in the WIC food packages. United States Department of Agriculture Food and Nutrition Service website. Accessed October 14, 2015.

10. Fung EB, Ritchie LD, Walker BH, Gildengorin G, Crawford PB. Randomized, controlled trial to examine the impact of providing yogurt to women enrolled in WIC. J Nutr Educ Behav. 2010;42(3 Suppl):S22-S29.