The principles of genetics and evolution help to explain the emergence of the aberrant phenomenon of lactose tolerance. Darwin referred to food as a major factor in selective pressures. Lactose digestion is most effective in illustrating how a certain food, by indirectly favoring the survival of those able to digest that substance, can influence the evolutionary process of man.

Clinical and nutritional consequences of lactose digestion in adults must be examined in relation to malabsorption, intolerance, milk rejection, and symptoms and their recognition. Estimates of how frequently milk intolerance will be a clinically significant problem in adults vary with the nature of the associated gastrointestinal disorders and the format of the individual studies.

There is a series of interrelated physiologic events affecting the amount of undigested sugar and fluid that the small intestine, and subsequently the colon, must metabolize or reabsorb. A balance of these factors tends to prevent symptoms when the stomach, small intestine, and colon can compensate for the increased solute load, but abdominal discomfort or diarrhea occur when these small intestinal and colo-nic physiologic mechanisms are loaded beyond their capacity. The role of the colonic flora in metabolizing unabsorbed sugar and the importance of colonic salvage of unabsorbed carbohydrate are important variables in the symptom complex. Secondary lactase deficiency due to infectious gastroenteritis and malnutrition represents a distinct clinical syndrome and must be distinguished from lactose intolerance.

Dietary recommendations must take account of lactose maldigestion. Milk and dairy product consumption will vary among lactose-maldigesting and milk-intolerant individuals. Lactose-reduced or lactose-free products are available to lactose-intolerant individuals who wish to drink milk and milk-based products. Nevertheless, dietary recommendations must be modified and respectful of those who do not drink milk. Accordingly, appropriate alternatives to milk and other lactose-containing foods must be identified and guidance provided in developing nutritionally equivalent diets.

See also: Calcium. Celiac Disease. Dairy Products. Osteoporosis. Pregnancy: Nutrient Requirements.

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