Management and treatment of lactose malabsorption

Synthesis of novel lactose-derived oligosaccharides by two-step enzymatic reactions and structural characterization of the oligomers

Exploitation of the added value of lactose by enzymatic synthesis of novel lactose-derived oligosaccharides has been a subject of increasing research interests. In this study, a strategy of two-step enzymatic reactions was designed to first synthesize galacto-oligosaccharide (GOS) from lactose by β-galactosidase, and then the novel oligosaccharides were synthesized by inulosucrase (IS) using the obtained GOS and sucrose as the substrates. The recombinant IS was initially expressed by employing the IS gene from Lactobacillus gasseri DSM 20604. The appropriate synthesis conditions by the IS were determined as: reaction time of 12 h, the concentration of IS at 25 U/mL, GOS to sucrose ratio of 1:2, and the total substrate concentration of 500 g/L. Purification of the synthesized oligosaccharides in the reaction mixture was done by fermentation with Kluyveromyces lactis CICC 1773 to remove the carbohydrate by-products, and HPLC on an oligosaccharide column. The purified oligosaccharides, namely, Oligo-1, Oligo-2, and Oligo-3 were determined for their monosaccharide components to be galactose and glucose in the molar ratios of 0.230:0.770, 0.522:0.478 and 0.637:0.363, respectively. These three oligosaccharides had relative molecular masses of 666.18, 990.26, and 1314.43, corresponding to the degree of polymerization (DP) value of 4, DP6, and DP8, respectively. NMR spectroscopic studies of the oligosaccharides revealed a common branched structure consisting of three glucosides, one of which was linked with one (Oligo-1), three (Oligo-2) and five galactosides (Oligo-3), respectively. These lactose-derived oligosaccharides with the structural patterns that were not reported earlier represented novel potential prebiotic agents for use in functional foods.

Food Intolerances, Food Allergies and IBS: Lights and Shadows

This narrative review delves into the intricate relationship between irritable bowel syndrome (IBS) and food intolerances. IBS, a chronic functional gastrointestinal disorder, is characterized by symptoms like abdominal pain and altered bowel habits. The prevalence of IBS has increased globally, especially among young adults. Food and dietary habits play a crucial role in IBS management. About 85-90% of IBS patients report symptom exacerbation linked to specific food consumption, highlighting the strong connection between food intolerances and IBS. Food intolerances often exhibit a dose-dependent pattern, posing a challenge in identifying trigger foods. This issue is further complicated by the complex nature of gastrointestinal physiology and varying food compositions. This review discusses various dietary patterns and their impact on IBS, including the low-FODMAP diet, gluten-free diet, and Mediterranean diet. It highlights the importance of a personalized approach in dietary management, considering individual symptom variability and dietary history. In conclusion, this review emphasizes the need for accurate diagnosis and holistic management of IBS, considering the complex interplay between dietary factors and gastrointestinal pathophysiology. It underlines the importance of patient education and adherence to treatment plans, acknowledging the challenges posed by the variability in dietary triggers and the psychological impact of dietary restrictions.

Exploring Therapeutic Digestive Enzyme Landscape in India: Current Evidence, Profit Motives, Regulations, and Future Perspectives

This analysis critically examines the profit-driven marketing of digestive enzymes as over-the-counter (OTC) supplements in the context of India, expressing ethical concerns regarding pharmaceutical companies prioritizing financial gain over genuine public health needs within the lucrative OTC supplement market. The review delves into various enzymes, their mechanisms of action, uses, adverse drug reactions, and provides evidence from various studies. The research method involves the exploration of profit-driven strategies employed by pharmaceutical companies, addressing regulatory challenges, investigating the gap between dietary supplements and pharmaceutical drugs, and emphasizing the impact of direct-to-consumer advertising on self-diagnosis and overuse. Additionally, the study reviews various e-pharmacy platforms in India, assessing formulations and pricing. Key findings highlight the diverse formulations on these platforms, exposing insights into cost variations and indicating a regulatory gap that necessitates a comprehensive re-evaluation by Indian and international authorities. The analysis emphasizes the influence of direct-to-consumer advertising on behavior and potential health risks, raising ethical concerns about oversimplified health claims that overlook the necessity for individualized treatment plans. In conclusion, the study underscores the ethical complexity of prioritizing profit over public health and advocates for regulatory re-evaluation, exploring broader implications such as cultural influences and alternative therapies. The evolving landscape, featuring plant-based and microbe-derived alternatives, is presented as transformative, particularly in conditions like celiac disease.

Lactose malabsorption and intolerance: What is the correct management in older adults?

Lactose malabsorption is a very common condition due to intestinal lactase deficiency. Post weaning, a genetically programmed and irreversible reduction of lactase activity occurs in the majority of the world's population. Lactose malabsorption does not necessarily result in gastrointestinal symptoms, i.e. lactose intolerance, which occurs in approximately one third of those with lactase deficiency. In the absence of well-established guidelines, the common therapeutic approach tends to exclude milk and dairy products from the diet. However, this strategy may have serious nutritional disadvantages. Mainly in particular categories, such as the older adults, the approach to lactose malabsorption may deserve careful considerations. Milk and dairy products are an important supply of a wide range of nutrients that contribute to meet the nutritional needs in different life stages. Dietary composition can significantly impact the mechanisms leading to age-related loss of bone mineral density, skeletal muscle mass or function and overall risk of sarcopenia. Moreover, in the latest years, different lines of evidence have highlighted an association between dairy intake and prevention of chronic diseases as well as all-cause mortality. The aim of this opinion paper is to provide an overview of lactose malabsorption and intolerance in the older adults and their implications in clinical practice.

Lactose Content and Selected Quality Parameters of Sheep Milk Fermented Beverages during Storage

The aim of the research was to evaluate lactose content and rheological, physical, chemical, and organoleptic parameters during the storage of fermented beverages made from sheep's milk. The research was carried out on natural, probiotic, and Greek-type yogurts, as well as kefir. The products were made using the thermostat method from the milk of 42 East Frisian sheep in the middle lactation period, in duplicate. Lactose contents, active and titratable acidity, color by the L*a*b*C*h* system, and rheological parameters (hardness, consistency, consistency, and viscosity) were tested, and organoleptic assessments were carried out on the first, seventh, fourteenth, and twenty-first days of storing the drinks at 4 °C. Of all drinks, the highest reduction in lactose after 21 days of storage was found to occur in kefir (52% reduction) and, among the yogurts, in the Greek yogurt (41% reduction). The product with the lowest lactose content, regardless of the storage period, was kefir. This indicates that kefir is more suitable than yogurt for people with partial lactose intolerance. Effects of both inoculation type and beverage storage time were shown to exist for all parameters. It was also found that kefirs suffered deterioration in most rheological parameters and, in general organoleptic evaluation in the final period of storage. Based on our analysis, the optimal storage time for natural yogurts and sheep's milk kefirs at 4 °C was 21 and 14 days, respectively.

Importance of Carbohydrate Quality: What Does It Mean and How to Measure It?

Dietary carbohydrates are our main source of energy. Traditionally, they are classified based on the polymer length between simple and complex carbohydrates, which does not necessarily reflect their impact on health. Simple sugars, such as fructose, glucose, and lactose, despite having a similar energy efficiency and caloric content, have very distinct metabolic effects, leading to increased risk for various chronic diseases when consumed in excess. In addition, beyond the absolute amount of carbohydrate consumed, recent data point out that the food form or processing level can modulate both the energy efficiency and the cardiometabolic risk associated with specific carbohydrates. To account for both of these aspects-the quality of carbohydrates as well as its food form-several metrics can be proposed to help identifying carbohydrate-rich food sources and distinguish between those that would favor the development of chronic diseases and those that may contribute to prevent these. This review summarizes the findings presented during the American Society of Nutrition Satellite symposium on carbohydrate quality, in which these different aspects were presented.

Role of milk carbohydrates in intestinal health of nursery pigs: a review

Intestinal health is essential for the resistance to enteric diseases and for nutrient digestion and absorption to support growth. The intestine of nursery pigs are immature and vulnerable to external challenges, which cause negative impacts on the structure and function of the intestine. Among nutritional interventions, the benefits of milk are significant for the intestinal health of pigs. Milk coproducts have traditionally been used in starter feeds to improve the growth of nursery pigs, but their use is somewhat limited due to the high costs and potential risks of excessive lactose on the intestine. Thus, understanding a proper feeding level of milk carbohydrates is an important start of the feeding strategy. For nursery pigs, lactose is considered a highly digestible energy source compared with plant-based starch, whereas milk oligosaccharides are considered bioactive compounds modulating intestinal immunity and microbiota. Therefore, milk carbohydrates, mainly composed of lactose and oligosaccharides, have essential roles in the intestinal development and functions of nursery pigs. The proper feeding levels of lactose in starter feeds could be variable by weaning age, body weight, or genetic lines. Effects of lactose and milk oligosaccharides have been broadly studied in human health and animal production. Therefore, this review focuses on the mechanisms of lactose and milk oligosaccharides affecting intestinal maturation and functions through modulation of enterocyte proliferation, intestinal immunity, and intestinal microbiota of nursery pigs.

A short update on new approaches to celiac disease

Celiac disease is an autoimmune enteropathy of the small intestine, related to gluten intolerance occurring in genetically predisposed patients. Currently, the only available treatment is a lifelong gluten-free diet. However, the total avoidance of gluten is difficult and poses a challenge to patients, nutritionists and treating physicians. For this reason, scientists have developed in recent years new therapeutic approaches complementary to dietary treatment, such as modification of gluten to make gliadin non-toxic, reduction of the inflammatory response with elafin and Lactococcus Lactis, degradation of gluten by endoproteolytic enzymes, and correction of nutritional deficiencies by adding pseudo-cereals to the diet of celiac patients. This literature review focuses on the different treatment strategies for celiac disease previously studied and summarizes the latest advances in this field.

Whole Cow's Milk but Not Lactose Can Induce Symptoms in Patients with Self-Reported Milk Intolerance: Evidence of Cow's Milk Sensitivity in Adults

BACKGROUND

Lactose intolerance is the most frequent food intolerance, but many subjects with self-reported milk intolerance (SRMI) are asymptomatic at lactose hydrogen breath test (LHBT). The aim of this study was to evaluate the frequency of lactose intolerance in SRMI patients and their clinical characteristics.

METHODS

In a retrospective study, the clinical records of 314 SRMI patients (259 females, mean age: 39.1 ± 13.5 years) were reviewed; 102 patients with irritable bowel syndrome (IBS) served as controls. In a prospective study, 42 SRMI patients, negatives at the LHBT, underwent a double-blind, placebo-controlled (DBPC) whole cow's milk challenge.

RESULTS

In the retrospective study, only 178 patients (56%) were lactose maldigesters and intolerant at LHBT; 68% of the subjects with SRMI were suffering from IBS; 74% reported dyspepsia (p = 0.0001 vs. IBS controls); and weight loss was recorded in 62 SRMI patients (20%) (p = 0.01 vs. IBS controls). Duodenal histology showed intra-epithelial lymphocytosis in about 60% of cases. In the prospective study, 36 patients (86%) experienced symptoms during the DBPC cow's milk challenge, and only 4 patients (9%) reacted to placebo (p = 0.0001).

CONCLUSIONS

A percentage of SRMI patients were not suffering from lactose intolerance. DBPC revealed that SRMI patients had clinical reactions when exposed to whole cow's milk.

Evaluation of a Digital Handheld Hydrogen Breath Monitor to Diagnose Lactose Malabsorption: Interventional Crossover Study

Background

Lactose malabsorption is a common condition that affects a broad segment of the population. Clinical diagnosis based on symptom recall can be unreliable and conventional testing can be inconvenient, requiring expensive laboratory-based equipment and conduction of the testing in a clinical setting.

Objective

The aim of this study is to assess the performance of a digital handheld hydrogen breath monitor (GIMate) in diagnosing lactose malabsorption compared to a US Food and Drug Administration (FDA)–cleared device (H2 Check) for the same indication.

Methods

An interventional crossover study was performed in adult participants with a prior confirmed diagnosis of lactose malabsorption or a suspected history of lactose intolerance.

Results

A total of 31 participants (mean age 33.9 years) were enrolled in the study. There was 100% positive percent agreement and 100% negative percent agreement between the GIMate monitor and the H2 Check. Correlation between gastrointestinal symptoms and hydrogen values was positive at 0.82 (P<.001).

Conclusions

The digital handheld GIMate breath monitor achieved equivalent diagnostic performance to that of an FDA-cleared device in the diagnosis of lactose malabsorption.

Trial Registration

ClinicalTrials.gov NCT04754724; https://clinicaltrials.gov/ct2/show/NCT04754724

Improvement in Lactose Tolerance in Hypolactasic Subjects Consuming Ice Creams with High or Low Concentrations of Bifidobacterium bifidum 900791

Although Bifidobacterium bifidum expresses lactase activity, no clinical trials have determined its impact on lactose-intolerant subjects. This study evaluated whether acute and chronic ingestion of ice creams containing B. bifidum 900791 at high (10⁷ CFU/g) or low (10⁵ CFU/g) concentrations improved lactose tolerance in hypolactasic subjects. Fifty subjects were selected based on a positive lactose (20 g) hydrogen breath test (HBT0) and the presence of digestive symptoms. The recruited subjects were required to perform breath tests after the acute ingestion of: (1) ice cream containing 20 g of lactose without a probiotic (HBT1); (2) the same ice cream, accompanied by a lactase tablet (HBT2); (3) the same ice cream containing the low or high dose of probiotic (HBT3-LD and HBT3-HD); and (4) after the chronic consumption of the ice cream without (placebo) or with the low concentration of probiotic for 1 month (HBT4). Significant decreases in H₂ excretion during HBT2 and HBT3-HD as well as digestive symptoms during HBT2, HBT3-HD and HBT3-LD were observed compared to HBT0 and HBT1, while the orocecal transit time increased. Chronic consumption of the probiotic ice cream did not enhance lactose tolerance compared to the placebo. These results suggest that the acute ingestion of ice cream containing high or low concentrations of B. bifidum 900791 improves lactose tolerance in hypolactasic subjects.

Use of a Novel Probiotic Formulation to Alleviate Lactose Intolerance Symptoms-a Pilot Study

Lactose intolerance is a common condition caused by lactase deficiency and may result in symptoms of lactose malabsorption (bloating, flatulence, abdominal discomfort, and change in bowel habits). As current data is limited, the aim of our study was to assess the efficacy of probiotics with a β-galactosidase activity on symptoms of lactose malabsorption and on the lactose hydrogen breath test (LHBT). The study group comprised eight symptomatic female patients with a positive LHBT. Patients were treated for 6 months with a probiotic formula with β-galactosidase activity (Bio-25, Ambrosia-SupHerb, Israel). All patients completed a demographic questionnaire as well as a diary for the assessment of symptom severity and frequency at entry, every 8 weeks, and at the end of the treatment period. Measurements of hydrogen (H₂) levels (parts per million, ppm) at each of these time points were also performed. End points were a decrease of 50% in symptom severity or frequency, and the normalization (decrease below cutoff point of 20 ppm) of the breath test. Mean age and mean body mass index (BMI) were 36.4 ± 18.6 years and 23.2 kg/m², respectively. Compared to baseline scores, the frequency of most symptoms, and the severity of bloating and flatulence, improved after treatment. Normalization of LHBT was obtained in only two patients (25%). In this pilot study, Bio-25, a unique formulation of probiotics with β-galactosidase activity, demonstrated symptom resolution in most patients with lactose malabsorption. A larger randomized trial is warranted to confirm these preliminary findings.

Development of Personalized Nutrition: Applications in Lactose Intolerance Diagnosis and Management

Recent discoveries in the “omics” field and the growing focus on preventive health have opened new avenues for personalized nutrition (PN), which is becoming an important theme in the strategic plans of organizations that are active in healthcare, food, and nutrition research. PN holds great potential for individual health optimization, disease management, public health interventions, and product innovation. However, there are still multiple challenges to overcome before PN can be truly embraced by the public and healthcare stakeholders. The diagnosis and management of lactose intolerance (LI), a common condition with a strong inter-individual component, is explored as an interesting example for the potential role of these technologies and the challenges of PN. From the development of genetic and metabolomic LI diagnostic tests that can be carried out in the home, to advances in the understanding of LI pathology and individualized treatment optimization, PN in LI care has shown substantial progress. However, there are still many research gaps to address, including the understanding of epigenetic regulation of lactase expression and how lactose is metabolized by the gut microbiota, in order to achieve better LI detection and effective therapeutic interventions to reverse the potential health consequences of LI.

The role of lactose in weanling pig nutrition: a literature and meta-analysis review

Lactose plays a crucial role in the growth performance of pigs at weaning because it is a palatable and easily digestible energy source that eases the transition from milk to solid feed. However, the digestibility of lactose declines after weaning due to a reduction in endogenous lactase activity in piglets. As a result, some lactose may be fermented in the gastrointestinal tract of pigs. Fermentation of lactose by intestinal microbiota yields lactic acid and volatile fatty acids, which may positively regulate the intestinal environment and microbiome, resulting in improved gastrointestinal health of weanling pigs. We hypothesize that the prebiotic effect of lactose may play a larger role in weanling pig nutrition as the global feed industry strives to reduce antibiotic usage and pharmacological levels of zinc oxide and supra-nutritional levels of copper. Evidence presented in this review indicates that high dietary lactose improves growth performance of piglets, as well as the growth of beneficial bacteria, particularly Lactobacillus, with the positive effects being more pronounced in the first 2 weeks after weaning. However, the risk of post-weaning diarrhea may increase as pigs get older due to reduced lactase activity, high dietary lactose concentrations, and larger feed intakes, all of which may lead to excessive lactose fermentation in the intestine of the pig. Therefore, dietary lactose levels exert different effects on growth performance and gastrointestinal physiological functions in different feeding phases of weanling pigs. However, no formal recommendation of lactose for weanling pigs has been reported. A meta-analysis approach was used to determine that diets fed to swine should include 20%, 15%, and 0 lactose from d 0–7, d 7–14, and d 14–35 post-weaning, respectively. However, sustainable swine production demands that economics must also be taken into account as lactose and lactose containing ingredients are expensive. Therefore, alternatives to lactose, so called “lactose equivalents” have also been studied in an effort to decrease feed cost while maintaining piglet performance with lower dietary lactose inclusions. In summary, the present review investigated dose-response effects of dietary lactose supplementation to exert positive responses and begin to elucidate its mechanisms of action in post-weaning pig diets. The results may help to replace some or all lactose in the diet of weanling pigs, while improving production economics given the high cost of lactose and availability in some swine production markets.

Dose-response and functional role of whey permeate as a source of lactose and milk oligosaccharides on intestinal health and growth of nursery pigs

Two experiments were conducted to evaluate dose-response and supplemental effects of whey permeate on growth performance and intestinal health of nursery pigs. In experiment (exp.) 1, 1,080 pigs weaned at 6.24 kg body weight (BW) were allotted to five treatments (eight pens/treatment) with increasing levels of whey permeate in three phases (from 10% to 30%, 3% to 23%, and 0% to 9% for phase 1, 2, and 3, respectively) fed until 11 kg BW and then fed a common phase 4 diet (0% whey permeate) until 25 kg BW in a 48-d feeding trial. Feed intake and BW were measured at the end of each phase. In exp. 2, 1,200 nursery pigs at 7.50 kg BW were allotted to six treatments (10 pens/treatment) with increasing levels of whey permeate from 0% to 18.75% fed until 11 kg BW. Feed intake and BW were measured during 11 d. Six pigs per treatment (1 per pens) were euthanized to collect the jejunum to evaluate tumor necrosis factor-alpha, interleukin-8 (IL-8), transforming growth factor-beta 1, mucin 2, histomorphology, digestive enzyme activity, crypt cell proliferation rate, and jejunal mucosa-associated microbiota. Data were analyzed using contrasts in the MIXED procedure and a broken-line analysis using the NLIN procedure of SAS. In exp. 1, increasing whey permeate had a quadratic effect (P < 0.05) on feed efficiency (G:F; maximum: 1.35 at 18.3%) in phase 1. Increasing whey permeate linearly increased (P < 0.05) average daily gain (ADG; 292 to 327 g/d) and G:F (0.96 to 1.04) of pigs in phase 2. In exp. 2, increasing whey permeate linearly increased (P < 0.05) ADG (349 to 414 g/d) and G:F (0.78 to 0.85) and linearly increased (P < 0.05) crypt cell proliferation rate (27.8% to 37.0%). The breakpoint from a broken-line analysis was obtained at 13.6% whey permeate for maximal G:F. Increasing whey permeate tended to change IL-8 (quadratic, P = 0.052; maximum: 223 pg/mg at 10.9%), to decrease Firmicutes:Bacteroidetes (P = 0.073, 1.59 to 1.13), to increase (P = 0.089) Bifidobacteriaceae (0.73% to 1.11%), and to decrease Enterobacteriaceae (P = 0.091, 1.04% to 0.52%) and Streptococcaceae (P = 0.094, 1.50% to 0.71%) in the jejunal mucosa. In conclusion, dietary inclusion of whey permeate increased the growth of nursery pigs from 7 to 11 kg BW. Pigs grew most efficiently with 13.6% whey permeate. Improvement in growth performance is partly attributed to stimulating intestinal immune response and enterocyte proliferation with positive changes in jejunal mucosa-associated microbiota in nursery pigs.

β-galactosidase Encapsulated in Carrageenan, Pectin and Carrageenan/Pectin: Comparative Study, Stability and Controlled Release

The present study investigated the encapsulation of β-galactosidase in carrageenan, pectin and its hybrid hydrogels by using the ionotropic gelation method. The material obtained was characterized by Fourier transform infrared spectroscopy (FTIR), thermogravimetric analysis (TG/DTG) and scanning electron microscopy (SEM). The effects of pH, temperature and storage time were evaluated in terms of the catalytic activity of the free and encapsulated enzyme. Addition studies were conducted evaluating the performance of catalytic activity in vitro conditions. Carrageenan, pectin and hybrid hydrogels presented encapsulation efficiency of 58 ± 1%, 72 ± 1% and 77 ± 2%, respectively. The pectin hydrogel showed the higher β-galactosidase activity in pH and temperature tests. However, the carrageenan hydrogel exhibited best stability after been stored for three months. Carrageenan and pectin hydrogels were 2.0 and 2.4 times more efficiently than commercial tablet in the releasing β-galactosidase under in vitro conditions, respectively. The results suggest that pectin and carrageenan hydrogels may be useful for the development of new formulation of β-galactosidase.

Lactose intolerance in children and adults

Lactose is a disaccharide found in milk and dairy products. Children and adults with lactose intolerance are unable to tolerate significant amounts of lactose because of an inadequate amount of the enzyme lactase. The condition occurs in three main types: primary, secondary, and primary adult-type hypolactasia. The use of milk in the diet of these individuals may lead to appearance of the irritable bowel syndrome. In persons with lactose intolerance symptoms include diarrhoea, dominated by abdominal colic, loud peristaltic sounds, increased flatulence and meteorism. A diagnosis of lactose intolerance can usually be made with a careful history, elimination of lactose from the diet, lactose tolerance test, hydrogen breath test and genetic testing. In the absence of appropriate tests in patients with suspected primary adult-type hypolactasia, diagnosis can be made as in patients with food allergy. Treatment is based on the restriction of lactose intake with the use of fermented milk products. However, especially for children, if milk and dairy products are eliminated from the diet, it is important to ensure D vitamin and calcium supplementation.

Lactose Malabsorption and Lactose Intolerance in Children with Inflammatory Bowel Diseases

Background

Insufficient vitamin D and calcium intake associated with the restricted intake of milk and dairy products can lead to poor health outcomes like malnutrition and abnormal bone mineralization. The aim of the study was to estimate the prevalence of primary and secondary lactose intolerance in children with IBD.

Methods

The study included 107 patients (mean age 14.07 ± 3.58 years; 46.7% boys) which includes 43 patients with Crohn's disease (CD), 31 with ulcerative colitis (UC), and 33 children with functional abdominal pain (AP-FGID). We analysed the result of the hydrogen breath test with lactose loading, two single nucleotide polymorphisms of the LCT gene (LCT-13910CC and LCT-22018GG). The results were analysed with MedCalc Statistical Software.

Results

Adult-type hypolactasia (ATH) was found in 31% of patients with IBD and 42.4% of AP-FGID (p = 0.2). Lactose malabsorption (LM) was found in 27.9% of patients with CD, in 22.6% with UC, and in 24.2% with AP-FGID (p = 0.8). Lactose intolerance (LI) was diagnosed in a similar percentage of patients in each group (p = 0.9). Secondary LI in IBD patients does not depend on the location, duration, and activity of the disease and the number of relapses (p > 0.05). The median time of lactose-free diet in CD was 10 months and in CU 24 months.

Conclusions

The incidence of LI, LM, and ATH does not differ among children with IBD from the population.

Bioactive molecules of probiotic bacteria and their mechanism of action: a review

The bacteria residing in the gut environment do play a pivotal role in metabolic activities of the host. The metabolites produced by these bacteria affect the physiology and health of the host. The gut bacteria are exposed to environmental conditions where multiple factors such as lifestyle, stress, antibiotics, host genetics and infections have an influence on them. In case of pathogenesis of a disease, the gut bacterial composition is altered which leads to a diseased state. This stage is due to colonization of bacterial pathogens in the gut environment. The pathological condition can be alleviated by administering probiotic strains into the gut environment. The probiotic strains produce therapeutic molecules such as amino acids, vitamins, bacteriocins, enzymes, immunomodulatory compounds and short-chain fatty acids. This review discusses recent evidences of the impact of bioactive molecules produced by probiotic bacteria and their mechanism of action in the gut environment to maintain homeostasis and health of the host without any effect on beneficial bacteria sharing the same niche. In addition, the manufacturing challenges of probiotic products for various applications are discussed here.

Lactose in processed foods: evaluating the availability of information regarding its amount

Patients with lactose intolerance, a high prevalence disease, should control the intake of food with lactose to avoid gastrointestinal symptoms. Since tolerance depends on the amount of lactose ingested, it is essential to discuss the availability of the amount of lactose information in processed foods, which is currently not mandatory. The study measured the availability of information on the amount of lactose on the labels of processed food that contained milk or lactose in the ingredient list. Then, we contacted the food industry to request this information. We evaluated 1,209 processed foods, of which 1,092 were traditional and 117 were diet/light/zero. Only 3,1% of the analyzed foods provided information on the amount of lactose in the labeled nutrition table. This information was more available in the diet/light/zero food group. Furthermore, of the 156 contacted companies, only 14 reported the amount of lactose contained in foods, 93 answered the request, but have not provided the amounts and 49 did not answer the request. We concluded that there is a low availability of information about the amount of lactose in processed foods.

Lactose intolerance: what is a correct management?

Individuals with Lactose Intolerance (LI) tend to exclude milk from their diet since this behavior seems to relieve the symptoms caused by the disease. However, milk is a food of high nutritional value, and complete exclusion of dairy products may favor the development of bone diseases such as osteopenia and osteoporosis. The objective of this review was to evaluate the scientific evidence on the adequate management of patients with LI. This study was carried out from the review of the scientific literature in PubMed and SciELO databases. Complete exclusion of conventional dairy products is not necessary since most individuals with LI can tolerate up to 12 grams of lactose daily in a single dose. Yogurts and cheeses matured for having low amounts of lactose are part of the strategy that allows consumption of dairy products by patients with LI. Currently, there is a diversity of products considered as "milk substitutes" and supplements aimed at individuals with LI. However, these strategies still require better-designed studies.

Analysis of lactase in lactose intolerance supplements

Lactase is the enzyme responsible for the digestion of the disaccharide lactose, and deficiency in this enzyme causes the prevalent medical condition lactose intolerance. Management of lactose intolerance can be achieved through the administration of lactase supplements. Lactase is an appropriate platform for advanced enzymatic study because its medical application is a motivator for student learning. The following is an upper-level biochemistry laboratory sequence that integrates student inquiry and exposure to advanced laboratory techniques. Students investigate three different lactase supplements through experimentation that includes the Bradford assay, SDS-PAGE, continuous and discontinuous kinetic assays, and zymography. Upon completion of this project, students compile their results and conclusions in a scientifically formatted paper comparing supplement protein content and activity. This safe and inexpensive laboratory project enriches student understanding of key biochemical concepts while mirroring work performed in a realistic research setting. © 2018 International Union of Biochemistry and Molecular Biology, 46(6):652-662, 2018.

Spray congealed lipid microparticles for the local delivery of β-galactosidase to the small intestine

Oral local delivery of therapeutic biologics is generally limited due to the multiple obstacles of the gastrointestinal (GI) tract, mainly represented by acidic stomach pH and digestive enzymes. In the present study, spray congealing was used to prepare solid lipid microparticles (SLMs) loaded with β-galactosidase (lactase), an enzyme used for the treatment of lactose intolerance, to achieve a local drug delivery to the small intestine. Lactase was characterized in terms of activity at different pH, kinetic parameters and proteolytic degradation by digestive enzymes. Then, five lipid excipients were used to prepare unloaded SLMs, which were tested regarding lipase-induced digestion. The lipid with the best performance (glyceryl trimyristate) was used to prepare lactase-loaded SLMs. Spray congealed SLMs were spherical with very good encapsulation efficiency (>95%). The ability of the SLMs to protect the enzyme from the degradation in gastric environment was correlated with the particle size and the best formulation preserved the lactase activity up to 70%. Lactase was promptly released in simulated intestinal environment, and an in vitro positive food effect was observed. The present study demonstrated the potential of spray congealing for the preparation of solid lipid formulations able to achieve local oral delivery of a biologic drug.

One-third of children with lactose intolerance managed to achieve a regular diet at the three-year follow-up point

AIM

This study described outcomes following treatment for lactose intolerance, which is common in children.

METHODS

The medical records of children aged 6-18 years who underwent lactose hydrogen breath testing at Dana-Dwek Children's Hospital, Tel Aviv, Israel, from August 2012 to August 2014 were analysed. We compared 154 children with gastrointestinal symptoms and positive lactose hydrogen breath tests to 49 children with negative test results.

RESULTS

Of the 154 children in the study group, 89 (57.8%) were advised to follow a lactose-restricted diet, 32 (20.8%) were advised to avoid lactose completely, 18 (11.7%) were instructed to use substitute enzymes, and 15 (9.7%) did not receive specific recommendations. Only 11 patients (7.1%) received recommendations to add calcium-rich foods or calcium supplements to their diet. Lactose reintroduction was attempted in 119 of 154 patients (77.3%), and 65 of 154 (42.2%) experienced clinical relapses. At the final follow-up of 3.3 years, 62.3% of the study children were still observing a restricted diet. Older children and those who were symptomatic during lactose hydrogen breath testing were more likely to be on a prolonged restricted diet.

CONCLUSION

Our long-term follow-up of lactose-intolerant children showed that only a third were able to achieve a regular diet.

MANAGEMENT OF ENDOCRINE DISEASE: Pitfalls on the replacement therapy for primary and central hypothyroidism in adults

Hypothyroidism is one of the most common hormone deficiencies in adults. Most of the cases, particularly those of overt hypothyroidism, are easily diagnosed and managed, with excellent outcomes if treated adequately. However, minor alterations of thyroid function determine nonspecific manifestations. Primary hypothyroidism due to chronic autoimmune thyroiditis is largely the most common cause of thyroid hormone deficiency. Central hypothyroidism is a rare and heterogeneous disorder characterized by decreased thyroid hormone secretion by an otherwise normal thyroid gland, due to lack of TSH. The standard treatment of primary and central hypothyroidism is hormone replacement therapy with levothyroxine sodium (LT4). Treatment guidelines of hypothyroidism recommend monotherapy with LT4 due to its efficacy, long-term experience, favorable side effect profile, ease of administration, good intestinal absorption, long serum half-life and low cost. Despite being easily treatable with a daily dose of LT4, many patients remain hypothyroid due to malabsorption syndromes, autoimmune gastritis, pancreatic and liver disorders, drug interactions, polymorphisms in DIO2 (iodothyronine deiodinase 2), high fiber diet, and more frequently, non-compliance to LT4 therapy. Compliance to levothyroxine treatment in hypothyroidism is compromised by daily and fasting schedule. Many adult patients remain hypothyroid due to all the above mentioned and many attempts to improve levothyroxine therapy compliance and absorption have been made.

Preparation, characterization and in vitro release of β-galactosidase loaded polyelectrolyte nanoparticles

Improving encapsulation efficacy (EE) and bioavailability of β-galactosidase (β-gal) is always a challenge due to its fragility. In this work, β-gal loaded β-chitosan (CS) nanoparticles (NPs) were successfully prepared based on ionic gelation technique and electrostatic attraction for improving its EE and in vitro releasing capacity. The particle size of β-gal loaded low and high molecular weight (LMW and HMW) β-CS NPs reached 584.37 and 652.46nm, with Zeta-potential (ZP) of 26.37 and 16.46mV under the optimal conditions, respectively. In vitro release study conducted at pH4.5 and 7.4 showed that β-gal loaded LMW and HMW β-CS NPs with EE of 68.32 and 58.64% sustained the release of the β-gal over 12h. The β-gal incorporated into β-CS NPs was confirmed with the results of physicochemical and structural properties of β-gal loaded β-CS NPs, and prepared NPs had hardly any cytotoxicity in the range of 0.1-1.0mg/mL. The results indicated that β-gal loaded β-CS NPs could serve as non-toxic delivery carriers for the treatment of lactose intolerance.

Increase in an Intracellular β-Galactosidase Biosynthesis Using L. reuteri NRRL B-14171, Inducers and Alternative Low-Cost Nitrogen Sources under Submerged Cultivation

The aim of this study was to select among lactic acid bacteria (LAB) and yeast a potential β-galactosidase producer, based on bioprocess parameters. From the selected microorganism,  different organic cheaper nitrogen sources (single and combined) with low cost for β-galactosidase production were evaluated. Lactobacillus reuteri B-14171 showed the highest enzymatic activity (1,286 U L−1), high productivity (28.78 U L h−1) and yield factor (82.32 U g−1), evidencing its potential for β-galactosidase production. All organic nitrogen sources tested were viable for the enzymatic production using L. reuteri B-14171. The MMRS casein (3.0 g L−1) + inactive beer yeast (3.0 g L−1) as nitrogen source increased the enzymatic activity (1269 U L−1) with 1.83 times lower production costs of culture medium when compared to MMRS-yeast extract B. The MMRS casein + inactive beer yeast has proved to be an innovative and cheaper nitrogen source for β-galactosidase production by L. reuteri B-14171.

Lactose malabsorption and intolerance: a review

A review on the current knowledge about lactose malabsorption and intolerance is presented including biochemistry, physiology, diagnosis and dietary management.

Effects of Probiotics, Prebiotics, and Synbiotics on Human Health

The human gastrointestinal tract is colonised by a complex ecosystem of microorganisms. Intestinal bacteria are not only commensal, but they also undergo a synbiotic co-evolution along with their host. Beneficial intestinal bacteria have numerous and important functions, e.g., they produce various nutrients for their host, prevent infections caused by intestinal pathogens, and modulate a normal immunological response. Therefore, modification of the intestinal microbiota in order to achieve, restore, and maintain favourable balance in the ecosystem, and the activity of microorganisms present in the gastrointestinal tract is necessary for the improved health condition of the host. The introduction of probiotics, prebiotics, or synbiotics into human diet is favourable for the intestinal microbiota. They may be consumed in the form of raw vegetables and fruit, fermented pickles, or dairy products. Another source may be pharmaceutical formulas and functional food. This paper provides a review of available information and summarises the current knowledge on the effects of probiotics, prebiotics, and synbiotics on human health. The mechanism of beneficial action of those substances is discussed, and verified study results proving their efficacy in human nutrition are presented.

[Efficacy of Lactose-free Milk in Korean Adults with Lactose Intolerance]

BACKGROUND/AIMS

Lactose-free milk (LFM) is available for nutrient supply for those with lactose intolerance (LI). However, there are no consistent results of the efficacy of LFM in LI subjects. We aimed to examine the changes of gastrointestinal (GI) symptoms and hydrogen breath test (HBT) values after ingestion of lactose contained milk (LCM) vs. LFM.

METHODS

From May 2015 to September 2015, thirty-five healthy adults with history of LCM-induced GI symptoms were recruited at a tertiary hospital. For the diagnosis of LI, HBT with LCM 550 mL (lactose 25 g) was performed every 20 minutes for 3 hours. The test was defined as "positive" when H2 peak exceeded 20 ppm above baseline values (ΔH2>20 ppm). When the subjects are diagnosed as LI, the second HBT using LFM 550 mL (lactose 0 g) was performed 7 days later. Subjects were asked to complete a questionnaire about the occurrence and severity of GI symptoms.

RESULTS

Among a total of 35 subjects, 31 were diagnosed with LI at first visit, and their LCM-related symptoms were abdominal pain (98.6%), borborygmus (96.8%), diarrhea (90.3%), and flatus (87.1%). The ΔH2 value in subjects taking LCM (103.7±66.3ppm) significantly decreased to 6.3±4.9 ppm after ingesting LFM (p<0.0001). There were also significant reduction in total symptom scores and the severity of each symptom when LCM was changed to LFM (p<0.0001).

CONCLUSIONS

This is the first report that LFM reduce LCM-related GI symptoms and H2 production in Korean adults. LFM can be an effective alternative for LCM in adults with LI.

Digestive Enzyme Supplementation in Gastrointestinal Diseases

BACKGROUND

Digestive enzymes are able to break down proteins and carbohydrates and lipids, and their supplementation may play a role in the management of digestive disorders, from lactose intolerance to cystic fibrosis. To date, several formulations of digestive enzymes are available on the market, being different each other in terms of enzyme type, source and origin, and dosage.

METHODS

This review, performed through a non-systematic search of the available literature, will provide an overview of the current knowledge of digestive enzyme supplementation in gastrointestinal disorders, discussion of the use of pancreatic enzymes, lactase (β-galactosidase) and conjugated bile acids, and also exploring the future perspective of digestive enzyme supplementation.

RESULTS

Currently, the animal-derived enzymes represent an established standard of care, however the growing study of plant-based and microbe-derived enzymes offers great promise in the advancement of digestive enzyme therapy.

CONCLUSION

New frontiers of enzyme replacement are being evaluated also in the treatment of diseases not specifically related to enzyme deficiency, whereas the combination of different enzymes might constitute an intriguing therapeutic option in the future.

Oral delivery of macromolecular drugs: Where we are after almost 100years of attempts

Since the first attempt to administer insulin orally in humans more than 90years ago, the oral delivery of macromolecular drugs (>1000g/mol) has been rather disappointing. Although several clinical pilot studies have demonstrated that the oral absorption of macromolecules is possible, the bioavailability remains generally low and variable. This article reviews the formulations and biopharmaceutical aspects of orally administered biomacromolecules on the market and in clinical development for local and systemic delivery. The most successful approaches for systemic delivery often involve a combination of enteric coating, protease inhibitors and permeation enhancers in relatively high amounts. However, some of these excipients have induced local or systemic adverse reactions in preclinical and clinical studies, and long-term studies are often missing. Therefore, strategies aimed at increasing the oral absorption of macromolecular drugs should carefully take into account the benefit-risk ratio. In the absence of specific uptake pathways, small and potent peptides that are resistant to degradation and that present a large therapeutic window certainly represent the best candidates for systemic absorption. While we acknowledge the need for systemically delivering biomacromolecules, it is our opinion that the oral delivery to local gastrointestinal targets is currently more promising because of their accessibility and the lacking requirement for intestinal permeability enhancement.

Ultrasonic Monitoring of Enzyme Catalysis; Enzyme Activity in Formulations for Lactose-Intolerant Infants

The paper introduces ultrasonic technology for real-time, nondestructive, precision monitoring of enzyme-catalyzed reactions in solutions and in complex opaque media. The capabilities of the technology are examined in a comprehensive analysis of the effects of a variety of diverse factors on the performance of enzyme β-galactosidase in formulations for reduction of levels of lactose in infant milks. These formulations are added to infant's milk bottles prior to feeding to overcome the frequently observed intolerance to lactose (a milk sugar), a serious issue in healthy development of infants. The results highlight important impediments in the development of these formulations and also illustrate the capability of the described ultrasonic tools in the assessment of the performance of enzymes in complex reaction media and in various environmental conditions.

The malabsorption of commonly occurring mono and disaccharides: levels of investigation and differential diagnoses

BACKGROUND

Adverse food reactions (AFR) have has recently attracted increased attention from the media and are now more commonly reported by patients. Its classification, diagnostic evaluation, and treatment are complex and present a considerable challenge in clinical practice. Non-immune-mediated types of food intolerance have a cumulative prevalence of 30% to 40%, while true (immune-mediated) food allergies affect only 2% to 5% of the German population.

METHOD

We selectively searched the literature for pertinent publications on carbohydrate malabsorption, with special attention to published guidelines and position papers.

RESULTS

Carbohydrate intolerance can be the result of a rare, systemic metabolic defect (e.g., fructose intolerance, with a prevalence of 1 in 25,000 persons) or of gastrointestinal carbohydrate malabsorption. The malabsorption of simple carbohydrates is the most common type of non-immune-mediated food intolerance, affecting 20% to 30% of the European population. This condition is caused either by deficient digestion of lactose or by malabsorption of fructose and/or sorbitol. Half of all cases of gastrointestinal carbohydrate intolerance have nonspecific manifestations, with a differential diagnosis including irritable bowel syndrome, intolerance reactions, chronic infections, bacterial overgrowth, drug side effects, and other diseases. The diagnostic evaluation includes a nutritional history, an H2 breath test, ultrasonography, endoscopy, and stool culture.

CONCLUSION

The goals of treatment for carbohydrate malabsorption are to eliminate the intake of the responsible carbohydrate substance or reduce it to a tolerable amount and to assure the physiological nutritional composition of the patient's diet. In parallel with these goals, the patient should receive extensive information about the condition, and any underlying disease should be adequately treated.

Enteric-coated capsule containing β-galactosidase-loaded polylactic acid nanocapsules: enzyme stability and milk lactose hydrolysis under simulated gastrointestinal conditions

In order to protect peroral β-galactosidase from being degraded and hydrolyse milk lactose efficiently in the environments of gastrointestinal tract, a double-capsule delivery system composed of enteric-coated capsule and polylactic acid (PLA) nanocapsules (NCs) was developed for encapsulation of β-galactosidase. β-galactosidase-loaded PLA NCs in the size range of 100–200 nm were prepared by a modified w1/o/w2technique. During the encapsulation process, dichloromethane/ethyl acetate (1 : 1, v/v) as the solvent composition, high-pressure homogenisation (150 bar, 3 min) as the second emulsification method and polyvinyl alcohol or Poloxamer 188 as a stabiliser in the inner phase could efficiently improve the activity retention of β-galactosidase (>90%). Subsequently, the prepared NCs were freeze-dried and filled in a hydroxypropyl methylcellulose phthalate (HP55)-coated capsule. In vitro results revealed that the HP55-coated capsule remained intact in the simulated gastric fluid and efficiently protected the nested β-galactosidase from acidic denaturation. Under the simulated intestinal condition, the enteric coating dissolved rapidly and released the β-galactosidase-loaded PLA NCs, which exhibited greater stability against enzymatic degradation and higher hydrolysis ratio (∼100%) towards milk lactose than the free β-galactosidase. These results suggest that this double-capsule delivery system represents promising candidate for efficient lactose hydrolysis in the gastrointestinal tract.

Zinc treatment ameliorates diarrhea and intestinal inflammation in undernourished rats

BACKGROUND

WHO guidelines recommend zinc supplementation as a key adjunct therapy for childhood diarrhea in developing countries, however zinc's anti-diarrheal effects remain only partially understood. Recently, it has been recognized that low-grade inflammation may influence stunting. In this study, we examined whether oral zinc supplementation could improve weight, intestinal inflammation, and diarrhea in undernourished weanling rats.

METHODS

Rats were undernourished using a northeastern Brazil regional diet (RBD) for two weeks, followed by oral gavage with a saturated lactose solution (30 g/kg) in the last 7 days to induce osmotic diarrhea. Animals were checked for diarrhea daily after lactose intake. Blood was drawn in order to measure serum zinc levels by atomic absorption spectroscopy. Rats were euthanized to harvest jejunal tissue for histology and cytokine profiles by ELISA. In a subset of animals, spleen samples were harvested under aseptic conditions to quantify bacterial translocation.

RESULTS

Oral zinc supplementation increased serum zinc levels following lactose-induced osmotic diarrhea. In undernourished rats, zinc improved weight gain following osmotic diarrhea and significantly reduced diarrheal scores by the third day of lactose intake (p < 0.05), with improved jejunum histology (p < 0.0001). Zinc supplementation diminished bacterial translocation only in lactose-challenged undernourished rats (p = 0.03) compared with the untreated challenged controls and reduced intestinal IL-1β and TNF-α cytokines to control levels.

CONCLUSION

Altogether our findings provide novel mechanisms of zinc action in the setting of diarrhea and undernutrition and support the use of zinc to prevent the vicious cycle of malnutrition and diarrhea.

Systematic appraisal of lactose intolerance as cause of increased need for oral thyroxine

CONTEXT

An increased need for T4 has been described in patients with different gastrointestinal disorders. However, there is a lack of systematic studies assessing the need for T4 in hypothyroid patients with lactose intolerance, a widespread and often occult disorder.

OBJECTIVE

The objective of the study was to assess the replacement T4 dose required in hypothyroid patients with lactose intolerance.

DESIGN

This was a cohort study.

SETTING

The study was conducted at an outpatient endocrinology unit in a University Hospital.

PATIENTS

The replacement T4 dose has been analyzed, from 2009 to 2012, in 34 hypothyroid patients due to Hashimoto's thyroiditis and lactose intolerance and being noncompliant with a lactose-free diet.

MAIN OUTCOME MEASURE

An individually tailored T4 dose was measured.

RESULTS

In all patients with isolated Hashimoto's thyroiditis, target TSH (median TSH 1.02 mU/L) was obtained at a median T4 dose of 1.31 μg/kg/d. In patients with lactose intolerance, only five of 34 patients reached the desired TSH (median TSH 0.83 mU/L) with a similar T4 dose (1.29 μg/kg/d). In the remaining 29 patients, the T4 dose was progressively increased and the target TSH (median TSH 1.21 mU/L) was attained at a median T4 dose of 1.81 μg/kg/d (+38%, P < .0001). In six of these patients, other gastrointestinal disorders were diagnosed, and their median T4 requirement was higher (2.04 μg/kg/d; +55%; P = .0032). In the remaining 23 patients with isolated lactose intolerance, a median T4 dose of 1.72 μg/kg/d (+31% P < .0001) has been required to attain pharmacological thyroid homeostasis.

CONCLUSIONS

These findings show that lactose intolerance significantly increased the need for oral T4 in hypothyroid patients.

A diagnostic approach to patients with suspected lactose malabsorption

BACKGROUND

The lactose breath test (LBT) is the standard technique for diagnosis of lactose malabsorption. However, it is time-consuming, strenuous for the patient and has been reported to have low sensitivity. The lactose intolerance quick test (LIQT) measures lactase activity in duodenal biopsies and may be performed as part of upper gastrointestinal endoscopy.

AIM

The purpose of this study was to assess the role of the LBT and LIQT in the case management of suspected lactose malabsorption.

METHODS

The study group included 69 consecutive patients evaluated by the LBT followed by the LIQT. The test results were compared, and the sensitivity, specificity, and predictive values of the LBT were calculated.

RESULTS

Mean age of the patients was 54.4 years, male/female ratio was 1:3, and mean body mass index was 25.2. None had celiac disease on duodenal biopsy. The LIQT was positive for hypolactasia in 55 patients (80 %): mild in 14 (25 %) and severe in 41 (75 %); 10 (18 %) were symptomatic during the LBT. The LBT was positive for lactose malabsorption in 32 patients (46 %). Of the 37 patients with normal findings on the LBT, 24 (65 %) had positive findings on the LIQT: 11 (30 %) mild hypolactasia, 13 (35 %) severe hypolactasia. In one case, the LBT was positive and the LIQT was negative. The LBT had a sensitivity of 56 %, specificity 93 %, positive predictive value 97 %, and negative predictive value 35 %.

CONCLUSIONS

The LBT may serve as a diagnostic screening tool for lactose malabsorption. Symptomatic patients with negative LBT results should be referred for second-line testing with the LIQT.