Primary adult lactose intolerance and the milking habit: a problem in biological and cultural interrelations. I. Review of the medical research

Dairying, diseases and the evolution of lactase persistence in Europe

In European and many African, Middle Eastern and southern Asian populations, lactase persistence (LP) is the most strongly selected monogenic trait to have evolved over the past 10,000 years1. Although the selection of LP and the consumption of prehistoric milk must be linked, considerable uncertainty remains concerning their spatiotemporal configuration and specific interactions2,3. Here we provide detailed distributions of milk exploitation across Europe over the past 9,000 years using around 7,000 pottery fat residues from more than 550 archaeological sites. European milk use was widespread from the Neolithic period onwards but varied spatially and temporally in intensity. Notably, LP selection varying with levels of prehistoric milk exploitation is no better at explaining LP allele frequency trajectories than uniform selection since the Neolithic period. In the UK Biobank4,5 cohort of 500,000 contemporary Europeans, LP genotype was only weakly associated with milk consumption and did not show consistent associations with improved fitness or health indicators. This suggests that other reasons for the beneficial effects of LP should be considered for its rapid frequency increase. We propose that lactase non-persistent individuals consumed milk when it became available but, under conditions of famine and/or increased pathogen exposure, this was disadvantageous, driving LP selection in prehistoric Europe. Comparison of model likelihoods indicates that population fluctuations, settlement density and wild animal exploitation-proxies for these drivers-provide better explanations of LP selection than the extent of milk exploitation. These findings offer new perspectives on prehistoric milk exploitation and LP evolution.

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.

Functional significance of single nucleotide polymorphisms in the lactase gene in diverse US patients and evidence for a novel lactase persistence allele at -13909 in those of European ancestry

OBJECTIVES

Recent data from mainly homogeneous European and African populations implicate a 140-bp region 5' to the transcriptional start site of LCT (the lactase gene) as a regulatory site for lactase persistence and nonpersistence. Because there are no studies of US nonhomogeneous populations, we performed genotype/phenotype analysis of the -13910 and -22018 LCT single nucleotide polymorphisms (SNPs) in New England children, mostly of European ancestry.

METHODS

Duodenal biopsies were processed for disaccharidase activities, RNA quantification by reverse transcription polymerase chain reaction (RT-PCR), allelic expression ratios by PCR, and genotyping and SNP analysis. Results were compared with clinical information.

RESULTS

Lactase activity and mRNA levels, and sucrase-to-lactase ratios of enzyme activity and mRNA, showed robust correlations with genotype. None of the other LCT SNPs showed as strong a correlation with enzyme or mRNA levels as did -13910. Data were consistent, with the -13910 being the causal sequence variant instead of -22018. Four individuals heterozygous for -13910T/C had allelic expression patterns similar to individuals with -13910C/C genotypes; of these, 2 showed equal LCT expression from the 2 alleles and a novel variant (-13909C>A) associated with lactase persistence.

CONCLUSIONS

The identification of -13910C/C genotype is likely to predict lactase nonpersistence, consistent with prior published studies. A -13910T/T genotype will frequently, but not perfectly, predict lactase persistence in this mixed European-ancestry population; a -13910T/C genotype will not predict the phenotype. A long, rare haplotype in 2 individuals with -13910T/C genotype but equal allele-specific expression contains a novel lactase persistence allele present at -13909.

Evolution and medicine in undergraduate education: a prescription for all biology students

The interface between evolutionary biology and the biomedical sciences promises to advance understanding of the origins of genetic and infectious diseases in humans, potentially leading to improved medical diagnostics, therapies, and public health practices. The biomedical sciences also provide unparalleled examples for evolutionary biologists to explore. However, gaps persist between evolution and medicine, for historical reasons and because they are often perceived as having disparate goals. Evolutionary biologists have a role in building a bridge between the disciplines by presenting evolutionary biology in the context of human health and medical practice to undergraduates, including premedical and preprofessional students. We suggest that students will find medical examples of evolution engaging. By making the connections between evolution and medicine clear at the undergraduate level, the stage is set for future health providers and biomedical scientists to work productively in this synthetic area. Here, we frame key evolutionary concepts in terms of human health, so that biomedical examples may be more easily incorporated into evolution courses or more specialized courses on evolutionary medicine. Our goal is to aid in building the scientific foundation in evolutionary biology for all students, and to encourage evolutionary biologists to join in the integration of evolution and medicine.

Adaptive genetic variation and population differences

Since the expansion of modern humans (Homo sapiens) from Africa to the rest of the world between 50,000 and 100,000 years ago, the human genome has been shaped not only by demographic history but also by adaptation to local environments, including regional climate, landscape, food sources, culture, and pathogens. Genetic differences among populations interact with environmental factors, such as diet and lifestyle, leading to differences in nutrient metabolism, which translate into differences in susceptibility to a variety of diseases. Individuals from different populations sharing the same environments can exhibit differences in disease risk, as do individuals from the same population living in various regions of the globe. Therefore, it is important to understand how adaptive genetic variations interact with environments to influence health. This knowledge will provide a broad foundation for designing experiments and approaches in nutrigenomics research and strengthening the knowledge base for dietary recommendations for disease prevention. The objectives of this chapter are to (1) understand the methodology employed in examining adaptive genetic variation across populations, (2) establish the importance of adaptive genetic variation to human health, and (3) discuss the implications for nutrigenomics research and disease prevention.

Lactase persistence in central Asia: phenotype, genotype, and evolution

The aim of the present study is to document the evolution of the lactase persistence trait in Central Asia, a geographical area that is thought to have been a region of long-term pastoralism. Several ethnic groups co-exist in this area: Indo-Iranian speakers who are traditionally agriculturist (Tajik) and Turkic speakers who used to be nomadic herders (Kazakh, Karakalpak, Kyrgyz, Turkmen). It was recently demonstrated that horse milking practice existed in the Botai culture of Kazakhstan as early as 5,500 BP ( Outram et al. 2009 ). However, the frequency of the lactase persistence trait and its genetic basis in Central Asian populations remain largely unknown. We propose here the first genotype-phenotype study of lactase persistence in Central Asia based on 183 individuals, as well as the estimation of the time of expansion of the lactase-persistence associated polymorphism. Our results show a remarkable genetic-phenotypic correlation, with the causal polymorphism being the same than in Europe (-13.910C>T, rs4988235). The lactase persistence trait is at low frequency in these populations: between 25% and 32% in the Kazakh population (traditionally herders), according to phenotype used, and between 11% and 30% in the Tajiko-Uzbek population (agriculturalists). The difference in lactase persistence between populations, even if small, is significant when using individuals concordant for both excretion of breath hydrogen and the lactose tolerance blood glucose test phenotypes (P = 0.018, 25% for Kazakh vs. 11% for Tajiko-Uzbeks), and the difference in frequency of the -13.910*T allele is almost significant (P = 0.06, 30% for Kazakhs vs. 19% for Tajiko-Uzbeks). Using the surrounding haplotype, we estimate a date of expansion of the T allele around 6,000-12,000 yrs ago, which is consistent with archaeological records for the emergence of agropastoralism and pastoralism in Central Asia.

Spatial patterns of variation due to natural selection in humans

Empowered by technology and sampling efforts designed to facilitate genome-wide association mapping, human geneticists are now studying the geography of genetic variation in unprecedented detail. With high genomic coverage and geographic resolution, these studies are identifying loci with spatial signatures of selection, such as extreme levels of differentiation and correlations with environmental variables. Collectively, patterns at these loci are beginning to provide new insights into the process of human adaptation. Here, we review the challenges of these studies and emerging results, including how human population structure has influenced the response to novel selective pressures.

Tracing the distribution and evolution of lactase persistence in Southern Europe through the study of the T(-13910) variant

We investigated the occurrence and intra-allelic variability of the T(-13910) variant located upstream of the lactase gene in 965 individuals from 20 different locations of Italy and Greece. The T(-13910) frequency ranges from 0.072 (Sardinia) to 0.237 (North-East Italy), with a statistically significant difference between North-East Italians and other Italian populations. The comparison of the lactose tolerance predicted by T(-13910) and that assessed by other studies using physiological tests shows a one-way statistically significant discrepancy that could be due to sampling differences. However, the possible role of other genetic factors underlying lactase persistence is worth exploring. The time of the most recent common ancestor and departures from neutrality of the T(-13910) allele were assessed using three microsatellite loci. Time estimates were found to be congruent with the appearance of dairy farming in Southern Europe and the occurrence of a single introgression event. Robust signals of selection can be observed in North-East Italy only. We discuss the possible role of cultural traits and genetic history in determining these observed micro-evolutionary patterns.

Population continuity, demic diffusion and Neolithic origins in central-southern Germany: the evidence from body proportions

The transition to agro-pastoralism in central Europe has been framed within a dichotomy of "regional continuity" versus exogenous "demic diffusion". While substantial genetic support exists for a model of demographic diffusion from an ancestral source in the Near East, archaeological data furnish weak support for the "wave of advance" model. Nevertheless, archaeological evidence attests the widespread introduction of an exogenous "package" comprising ceramics, cereals, pulses and domesticated animals to central Europe at 5600calBCE. Body proportions are under strong climatic selection and evince remarkable stability within regional lineages. As such, they offer a viable and robust alternative to cranio-facial data in assessing hypothesised continuity and replacement with the transition to agro-pastoralism in central Europe. Humero-clavicular, brachial and crural indices in a large sample (n=75) of Linienbandkeramik (LBK), Late Neolithic and Early Bronze Age specimens from the middle Elbe-Saale-Werra valley (MESV) were compared with Eurasian and African terminal Pleistocene, European Mesolithic and geographically disparate recent human specimens. Mesolithic Europeans display considerable variation in humero-clavicular and brachial indices yet none approach the extreme "hyper-polar" morphology of LBK humans from the MESV. In contrast, Late Neolithic and Early Bronze Age peoples display elongated brachial and crural indices reminiscent of terminal Pleistocene and "tropically adapted" recent humans. These marked morphological changes likely reflect exogenous immigration during the terminal Fourth millennium cal BC. Population expansion and diffusion is a function of increased mobility and settlement dispersal concomitant with significant technological and subsistence changes in later Neolithic societies during the late fourth millennium cal BCE.

The molecular signature of selection underlying human adaptations

In the last decade, advances in human population genetics and comparative genomics have resulted in important contributions to our understanding of human genetic diversity and genetic adaptation. For the first time, we are able to reliably detect the signature of natural selection from patterns of DNA polymorphism. Identifying the effects of natural selection in this way provides a crucial piece of evidence needed to support hypotheses of human adaptation. This review provides a detailed description of the theory and analytical approaches used to detect signatures of natural selection in the human genome. We discuss these methods in relation to four classic human traits--skin color, the Duffy blood group, bitter-taste sensation, and lactase persistence. By highlighting these four traits we are able to discuss the ways in which analyses of DNA polymorphism can lead to inferences regarding past histories of selection. Specifically, we can infer the importance of specific regimes of selection (i.e. directional selection, balancing selection, and purifying selection) in the evolution of a trait because these different types of selection leave different patterns of DNA polymorphism. In addition, we demonstrate how these types of data can be used to estimate the time frame in which selection operated on a trait. As the field has advanced, a general issue that has come to the forefront is how specific demographic events in human history, such as population expansions, bottlenecks, and subdivision of populations, have also left a signature across the genome that can interfere with our detection of the footprint of selection at particular genes. Therefore, we discuss this general problem with respect to the four traits reviewed here, and describe the ways in which the signature of selection can be teased from a background signature of demographic history. Finally, we move from a discussion of analyses of selection motivated by a "candidate-gene" approach, in which a priori information led to the analysis of specific gene, to discussion of "genome-scanning" approaches that are directed at discovering new genes that have been under positive selection. Such scans can be designed to detect those genes that have been positively selected in our divergence from chimpanzees, as well as those genes that have been under selection as human populations have migrated, differentiated, and adapted to specific geographic environments. We predict that both approaches will be applied in the future, enabling a greater insight into human species-wide adaptations, as well as the specific adaptations of human populations.

Lactose and lactase--who is lactose intolerant and why?

Lactase-phlorizin hydrolase (LPH) is expressed only in the small intestine and is confined to absorptive enterocytes on the villi with a tightly controlled pattern of expression along the proximal to distal and crypt-villus axes of the intestine. LPH expression is regulated mainly at the level of lactase (LCT) gene transcription that directs 2 phenotypes: a decline in LCT activity (LCT nonpersistence) in mid-childhood in the majority of the world's population, and maintenance of the lactase levels found in infancy (LCT persistence) in people of northern European extraction and scattered populations elsewhere. The molecular mechanisms that regulate these phenotypes are not completely understood. A population genetic association of lactase persistence with 2 single nucleotide polymorphisms in the distal 5'-flanking region of LCT (-13.9T and -22A) has been confirmed in northern Europeans, but this fails to explain lactase persistence found in some African groups. Any hypothesis for the control of lactase expression must reconcile the presence of high levels of activity in early life in all humans and the characteristic loss of activity found subsequently in many but not all people.

Linkage disequilibrium as a tool for detecting signatures of natural selection

Natural selection has been theoretically and empirically proven to alter patterns of linkage disequilibrium (LD). Reciprocally, recombination, the driving force behind LD, modifies the signature of natural selection by reintroducing variation in a punctuate manner across the genome. To date, efforts to identify genes that have been subjected to historical selective pressure by examining polymorphic variation and allelic association have frequently fallen short of unambiguously distinguishing selection from other biological mechanisms. Contemporary genetic maps that describe LD in fine detail represent a much needed tool that can be exploited by researchers aiming to tease apart these opposing signals.

Genetic approaches to studying common diseases and complex traits

Most common diseases and most quantitative traits that can be measured in human populations are complex genetic traits. That is, many genetic and nongenetic factors interact to determine the final phenotype, whether that phenotype is susceptibility to disease, or a quantifiable trait such as height, weight, serum cholesterol, or blood pressure. Identifying the genes that underlie the population variation in these phenotypes has been challenging. Recently, databases of common genetic variants, recognition of the patterns of genetic variation, and rapid genotyping methodologies have emerged, and the combination of these tools and resources will greatly facilitate genetic association studies, a potentially powerful method to map the genes for complex traits. However, care will be required in performing and interpreting these association studies. Until genome-wide studies are feasible, choosing candidate genes will be necessary. In addition, the choice of phenotype will likely influence the success of these gene mapping efforts. Finally, population genetic methods, including searching for genes under selection, may provide clues to the location of the genes for common disease and complex traits.

Genetic signatures of strong recent positive selection at the lactase gene

In most human populations, the ability to digest lactose contained in milk usually disappears in childhood, but in European-derived populations, lactase activity frequently persists into adulthood (Scrimshaw and Murray 1988). It has been suggested (Cavalli-Sforza 1973; Hollox et al. 2001; Enattah et al. 2002; Poulter et al. 2003) that a selective advantage based on additional nutrition from dairy explains these genetically determined population differences (Simoons 1970; Kretchmer 1971; Scrimshaw and Murray 1988; Enattah et al. 2002), but formal population-genetics-based evidence of selection has not yet been provided. To assess the population-genetics evidence for selection, we typed 101 single-nucleotide polymorphisms covering 3.2 Mb around the lactase gene. In northern European-derived populations, two alleles that are tightly associated with lactase persistence (Enattah et al. 2002) uniquely mark a common (~77%) haplotype that extends largely undisrupted for >1 Mb. We provide two new lines of genetic evidence that this long, common haplotype arose rapidly due to recent selection: (1) by use of the traditional F(ST) measure and a novel test based on p(excess), we demonstrate large frequency differences among populations for the persistence-associated markers and for flanking markers throughout the haplotype, and (2) we show that the haplotype is unusually long, given its high frequency--a hallmark of recent selection. We estimate that strong selection occurred within the past 5,000-10,000 years, consistent with an advantage to lactase persistence in the setting of dairy farming; the signals of selection we observe are among the strongest yet seen for any gene in the genome.

Testing evolutionary hypotheses about human biological adaptation using cross-cultural comparison

Physiological data from a range of human populations living in different environments can provide valuable information for testing evolutionary hypotheses about human adaptation. By taking into account the effects of population history, phylogenetic comparative methods can help us determine whether variation results from selection due to particular environmental variables. These selective forces could even be due to cultural traits-which means that gene-culture co-evolution may be occurring. In this paper, we outline two examples of the use of these approaches to test adaptive hypotheses that explain global variation in two physiological traits: the first is lactose digestion capacity in adults, and the second is population sex-ratio at birth. We show that lower than average sex ratio at birth is associated with high fertility, and argue that global variation in sex ratio at birth has evolved as a response to the high physiological costs of producing boys in high fertility populations.

Genetics and epidemiology of adult-type hypolactasia

The prevalence of adult-type hypolactasia varies from less than 5% to almost 100% between different populations of the world. The lowest prevalence has been found in northwestern Europe, around the North Sea, and the highest prevalence in the Far East. The reason for the variation is that selective (primary) hypolactasia is genetically determined by an autosomal recessive single gene. It is assumed that thousands of years ago all people had hypolactasia in the same way as most mammals do today. At that time in cultures where milk consumption was started after childhood, lactase persistence had a selective advantage. Those people with lactase persistence were healthier and had more children than people with hypolactasia, and the frequency of the lactase persistence gene started to increase. The present prevalence of hypolactasia can be explained fairly well by this culture historical hypothesis. This article reviews the evidence for the inheritance of adult-type hypolactasia and the occurrence of hypolactasia in different countries and populations of the world.

Effects of in vitro hyperthermia on fatty acids of red blood cells and plasma lipids from patients with multiple sclerosis

Heparinized blood from 43 patients with multiple sclerosis (MS) and 43 controls matched for age, sex and race were incubated at 42 degrees C for 24 h. The hematocrit values were determined before and after heating. The plasma and red blood cells (RBC) were separated and the plasma free fatty acids (FFA), total neutral lipids (NL; which included the triglycerides and cholesteryl esters), phospholipids (PL), and RBC lipids from 24 patients and 24 controls were isolated. The total amounts of the various FFA in the plasma and the relative percentage fatty acid compositions of the various FFA, NL, ester-linked fatty acids of plasma PL, RBC lipids as well as those of phosphatidylcholine (PC) and phosphatidylethanolamine (PE) fractions of RBC lipids were determined by gas-liquid chromatography (GLC). The hematocrit values were significantly higher in heated samples from both MS and controls. The results of fatty acid analyses from 24 pairs of heated and unheated MS and controls showed that the concentrations of total FFA and most of the fatty acids increased significantly in the heated plasma of both MS and control samples, compared to the respective unheated plasma samples. When the FFA values were expressed as relative percentage compositions, the results showed significant increases in palmitic, arachidonic and adrenic acids and significant decreases in oleic, linoleic and linolenic acids in the heated samples from MS and controls compared to the corresponding unheated samples. In NL the relative percentages of linoleic and arachidonic acids were significantly higher in the heated samples from both MS and controls, while in the PL, the percentages of linoleic acid were lower in the heated samples from both MS and controls, when compared to the corresponding unheated samples. The fatty acid compositions of the RBC lipids showed highly significant increases in palmitic plus palmitoleic, stearic and oleic acids and significant decreases in linoleic and most of the polyunsaturated acids in the heated MS samples compared to the unheated MS samples. In contrast, the fatty acid compositions of the RBC lipids from heated controls showed significant increase in only palmitic plus palmitoleic acids and significant decreases in linoleic and arachidonic acids, compared to the values from unheated controls. The results show that the RBC membranes from MS were more affected by the heat than those of control RBC, indicating possible differences between blood from MS patients and controls.

Prediction of lactose malabsorption in referral patients

Two hundred forty-two patients referred for various gastrointestinal complaints were evaluated for clinical parameters that would predict findings of lactose malabsorption. Breath hydrogen and blood glucose lactose tests were performed after ingestion of 50 g lactose. Presenting complaints, duration of symptoms, and patient demographics such as age, sex, and ethnic heritage were not different between lactose malabsorbers and absorbers as defined by the breath hydrogen lactose test. Food-related symptoms in general and after specific foods such as milk, ice cream, cheese, and yogurt were also similar between groups. Prior to testing, 30% of malabsorbers (N = 161) and 36% of absorbers (N = 81) reported lactose-related symptoms (P = NS). The blood glucose response to lactose was abnormal in 60% of malabsorbers and 15% of absorbers. This study confirmed our impression that it is difficult to predict lactose absorption status by clinical parameters. The majority of our lactose malabsorber patients were unaware of lactose-associated symptoms. Furthermore, symptom assessment, demographics, food history, and blood glucose testing did not predict abnormal hydrogen responses to lactose.

Complications of enteral nutrition

Complications may arise during enteral feeding that are usually related to the diameter and rigidity of the tube or the delivery, composition, and sterility of the feed uses. By using a soft, fine bore tube to deliver a sterile feed of known composition, by continuous infusion rather than as a bolus, most of these complications can be avoided.

Yogurt--an autodigesting source of lactose

Large quantities of yogurt are consumed by some lactase-deficient population groups. We used breath hydrogen measurements to determine whether lactase-deficient subjects absorbed lactose in yogurt better than lactose in milk. Ingestion of 18 g of lactose in yogurt resulted in only about one third as much hydrogen excretion as a similar load of lactose in milk or water, indicating a much better absorption of lactose in yogurt. Ingestion of yogurt also resulted in fewer reports of diarrhea or flatulence than did a similar quantity of lactose ingested in milk or a water solution. The enhanced absorption of lactose in yogurt appeared to result from the intraintestinal digestion of lactose by lactase released from the yogurt organisms. This autodigesting feature makes yogurt a well-tolerated source of milk for lactase-deficient persons and may explain the widespread consumption of yogurt by lactase-deficient population groups.