Hope on the horizon9 July 2021
A common cause of discomfort in a world where dairy products are so prevalent, lactose intolerance is the subject of ongoing research, and the results could have far-reaching ramifications. Jim Banks looks at the condition and how treatments are evolving, and dietary alternatives are becoming easier to find.
Dairy products are a staple of many households’ weekly shop and, despite the rise of competing products and a consequent decline in sales, they are widely consumed, particularly in Europe and the US. There are many people, however, who cannot enjoy them because of an increasingly common and physically taxing ailment – lactose intolerance.
This digestive disorder is caused by the body’s inability to produce sufficient levels of lactase, which is the enzyme required to digest the main carbohydrate present in dairy products – lactose. While it is common around the world, the number of people who suffer with it is rising, even in regions with relatively low prevalence.
For some, the condition starts at birth if there is a mutation of the LCT gene, which causes a lifelong inability to produce lactase. For others, onset is later, as this gene becomes less active, and most sufferers see the condition develop over time. In some cases, it can be brought on by an external factor, such as a virus or infection that causes temporary damage to the small intestine, though often it recedes once the gut is healed.
Demographic trends mean that lactose malabsorption and intolerance are growing problems as the global population continues to increase and the average lifespan in many economies becomes longer. An ageing population leads to more people dealing with a less active LCT gene as they grow older. The disorder has, in fact, become relatively common, affecting millions of people just in North America and Europe, even though they are among the regions with the lowest incidence. According to the American Gastroenterological Association (AGA), somewhere in the region of 50 million adults in the US are currently lactose intolerant (LI).
On the plus side, it is not a life-threatening condition. In fact, it is generally harmless, though it can cause extreme discomfort in some instances.
The AGA lists common physical symptoms – bloating, cramps, gas, diarrhoea and an upset stomach – which often present 30 minutes to two hours after eating or drinking foods that have lactose, usually milk products, though their severity varies between individuals.
In some ways, treating the condition is simple, but there is still a concerted effort to provide more efficacious treatments – and more alternative foods – that can greatly reduce the suffering of those in need.
A medical path to relief
The most obvious approach to treating lactose intolerance is to avoid foods containing lactose. That sounds simple, but there are caveats. Making drastic changes to diet is not an easy thing for some people, and there are risks involved.
Avoiding dairy products is not as straightforward as it sounds, despite many more alternatives hitting the supermarket shelves in recent years. There is also the possibility that lactose intolerant consumers could end up lacking some vital nutrients if they eliminate dairy products but do not replace them with the right foods, specifically those containing sufficient levels of calcium and vitamin D.
If those nutrients are lacking, more severe medical conditions can result. A diet lacking in calcium, for example, can lead to osteoporosis, where bones become brittle and more likely to break. Vitamin D deficiency can also lead to skeletal problems and it has been associated with rickets, in which bone tissues do not mineralise properly, the result being soft bones and deformities.
Another potential treatment option is to eat a normal diet but also introduce lactase in supplement form. Products such as Lactaid, for example, can be taken to provide enough lactase to meet the amount of lactose in a meal or drink. Dosage must be measured proportionally, so it is important to have an accurate idea of how much lactose is being consumed.
Whichever option is chosen, one fact remains – treatment is always just to alleviate or prevent symptoms as there is no cure.
Despite that fact, there is a distinct desire among the lactose-intolerant community to have more effective treatments made available. Ritter Pharmaceuticals, which develops innovative therapeutic products that modulate the gut microbiome to treat gastrointestinal diseases, is one company engaged in the pursuit of such a treatment, and its review of recent market research surveying patients and physicians saw both groups express an unmet need.
Particularly among moderate-severe LI patients, there is a feeling that current treatment options do not sufficiently address symptoms, require high compliance, and for some are undesirable to follow. The company also noted in its analysis of comprehensive market studies that while most patients report making attempts to reduce or avoid dairy products as their first move to prevent symptoms, it was often found to be challenging and undesirable.
In fact, its analysis of 2019 data showed that 92% of LI sufferers would like to eat some dairy and 66% of LI sufferers find it difficult to avoid dairy.
Ritter was, at the time, involved in a Liberatus phase-||| trial of high-concentration galacto-oligosaccharide RP-G28 for lactose intolerance. That trial failed to demonstrate statistical significance in its results, showing little or no little difference compared with the placebo. Since then, however, trials have shown improved results.
In April 2020, Wiliam Chey and William Sandborn, who sit on the board of Ritter, were part of a research team that reported trial results showing that RP-G28 for 30 days significantly reduced symptoms and altered the fecal microbiome in patients with LI. Additionally, results showed patients were consuming significantly higher amounts of milk and dairy, with significant improvements in their global assessments compared with placebo.
In short, better treatments are in great demand and researchers are showing some promising results. Nevertheless, the best defence against symptoms is still to avoid lactose altogether, and the food industry is making it far easier for consumers to make dietary changes that provide the right nutrients and are not too onerous.
Foods created to feed wellness
While the community of people suffering the inconvenience and discomfort of lactose intolerance wait for more effective treatments to emerge, the best strategy remains a change in diet to eliminate lactose as far as possible. Luckily, food producers have access to an ever-growing range of foods that cater to their needs.
In fact, these foods have found a market beyond those dealing with lactose intolerance, and the number of people moving to a dairy-free or reduced-dairy diet has been growing steadily in recent years.
According to NPD Group, milk consumption represented a 15% share of all eating occasions in the US, but by 2019 that had fallen to just 9%, and US milk consumption continues to fall. Meanwhile, sales of non-dairy alternatives have been rising. According to research by Nielsen, US sales have grown by 23% in the past four years.
Soy milk and, to a greater extent, almond milk are now commonplace on supermarket shelves and, while not to everyone’s tastes, they have made significant inroads into the dairy market – as have other alternatives made from oats, hemp, cashews, coconut and more. At the same time, however, the dairy industry has responded, with lactose-free milk having a significant impact on the supermarket shelf.
Lactose-free milk – produced by treating dairy milk with the enzyme lactase – is setting new sales records each year. Market research from Technavio suggests that the market will expand by $118m between 2019 and 2022, with growth coming in the US, Europe and Asian, while Nielsen estimates that around $1.2bn of lactose-free milk is already sold around the world each year.
Indeed, the growth in sales of lactose-free milk seems to be outpacing its plant-based alternatives, at least in the US. Figures for 2019 supplied by market research firm IRI suggest the US market for lactosefree milk grew twice as fast as sales of plant-based alternatives. That said, the market for almond milk is growing rapidly and, again in 2019, sales of oat-based beverages grew by 872% in the US, though from a low base – up to $68m from only $7m in 2018. Milk is obviously the main battleground for the dairy industry in its attempts to counteract the rise in plant-based substitutes, but lactose is a core ingredient in many foods. There is much for the food industry to do to create and promote foods free from lactose, but the outlook for sufferers is positive indeed.
While researchers work on more effective supplements that can allow sufferers of lactose intolerance to consume whatever foods they choose, food producers will no doubt continue to develop dietary alternatives for anyone who feels a dairy-free diet might be healthier for them as individuals, whether they are lactase-deficient or not.
Highest prevalence of lactose intolerance
1. Ghana - 100%
2. Malawi - 100%
3. South Korea - 100%
4. Yemen - 100%
5. Solomon Islands - 99%
6. Armenia - 98%
7. Vietnam - 98%
8. Zambia - 98%
9. Azerbaijan - 96%
10. Oman - 96%
Lowest prevalence of lactose intolerance
1. Denmark - 4%
2. Ireland - 4%
3. Sweden - 7%
4. United Kingdom - 8%
5. New Zealand - 10%
6. Netherlands - 12%
7. Norway - 12%
8. Niger - 13%
9. Belgium - 15%
10. Cyprus - 16%
Source: World Population Review