Awareness of Lactose Intolerance Disorder in Saudi Arabia Population.

Background: Lactose intolerance is defined as "Lactose malabsorption with gastrointestinal symptoms." Also, lactose malabsorption can be defined as "Not all ingested lactose was absorbed and that some has reached the large intestine." The common symptoms associated with the maldigestion of lactose are bloating, diarrhoea, nausea, and abdominal pain. Aim: The current study aims to assess knowledge of people awareness of the lactose intolerance disorder and its relation to nutrition and dietary habits in Saudi Arabia.
Methods: A descriptive cross-sectional approach was used targeting all accessible population in Saudi Arabia aging 18 years or more and accept to participate in the study. Data were collected from participants using an online pre-structured questionnaire. The researchers constructed the survey tool after intensive literature review and expert's consultation. The questionnaire covered the following data: participants' socio-demographic data like age, gender, and monthly income. Second section covered participants' dairy products intake with associated symptoms. Third part covered personal and family history of glucose intolerance disorder among the study participants. Awareness was assessed using multiple repose and mutually exclusive questions.
Results: A total of 1189 participants fulfilling the inclusion criteria completed the study questionnaire. Participants ages ranged from 18 to 58 years old with mean age of 25.1 ± 12.9 years. Exact of 692 (58.2%) participants were females. Exact of 104 (8.7%) of the study participants reported that they had lactose intolerance disorder which started at the age of 11 to 20 years among 41 (39.4%) and at the age of 21 to 30 years among 36 (34.6%). About 77% of the study participants know that lactose indolence disorder symptoms appear after eating dairy or its derivatives. A total of 45.8% reported that leaky gut syndrome (diarrhoea and bloating) is caused by symptoms that occur with lactose intolerance and 39.4% know lactose intolerance is an uncurable disease.
Conclusion: In conclusion, this study revealed that nearly one out of each three persons on Saudi Arabia is knowledgeable regarding lactose intolerance disorder and its related factors and relieving factors. Dairy products use in daily basis was reported among two thirds of the study population with abdominal distention and abdominal pain was the main accompanying symptoms. Copyright:

Introduction

Lactose intolerance is a disorder featured by experiencing digestive symptoms including bloating, diarrhoea, and gas after consuming foods or drinks that contain lactose.[1] The main natural sources of lactose sugar are milk and milk products such as cheese or ice cream.[2] Lactose malabsorption is the main cause of gastrointestinal symptoms among lactose intolerance sufferers.[34] Lactose malabsorption is a condition in which small intestine cannot digest or break down all the lactose persons eat or drink. Not everyone with lactose malabsorption has digestive symptoms after they consume lactose. Only people who have symptoms are lactose intolerant.[567]

Lactose intolerance is variable in its magnitude globally. In Africa and Asia, most people have lactose malabsorption.[89] In northern Europe, many people had a gene that help them to digest lactose after infancy, with less frequent lactose malabsorption syndrome.[1011] In the United States, nearly one third of the population have lactose malabsorption.[10]

Small intestine biopsy is the cornerstone procedure to diagnose lactose intolerance as it directly measures lactase activity. In spite of its invasive procedure making, it is scarcely accepted by patients except to be with gastrointestinal endoscopy for other reasons.[12] A lactose tolerance test can be used and mostly includes having a lactose load after an overnight fast and then measuring blood glucose concentration or breath hydrogen expiration. A baseline measurement of blood glucose or breath gases is taken before ingestion of the lactose, and then the measurements are repeated at 30 min intervals up to 2 to 3 h, respectively. An increase in blood glucose indicates lactose digestion.[1314] At the field of primary care, lactose intolerance mostly affects every time persons eat. So, persons need to be advised for the foods they eat every day. Although, many people can tolerate a certain amount of lactose and do not need to completely avoid it. This role can be managed by primary health care staff who provide the first line of care for general population.

Many people suffer from an intolerance of a disaccharide present in milk called lactose, this study aims to understand the awareness of Lactose Intolerance (LI) among common Saudi people and if they can detect their symptoms associated with LI. There is no such study available in literature, hence these results could provide a baseline data for further research in this area.

Methodology

A descriptive cross-sectional approach was used targeting all accessible population in Saudi Arabia aging 18 years or more and accept to participate in the study. A total of 1570 individuals received the study survey. Exact of 1198 respondents were eligible and completed the study questionnaire with participation rate of 76.3%. After obtaining permission from Institutional ethics committee, data collection started. Data were collected from participants using an online pre-structured questionnaire. The researchers constructed the survey tool after intensive literature review and expert’s consultation. Tool was reviewed using a panel of 3 experts for validation and applicability. Tool reliability was assessed using pilot study of 25 participants with reliability coefficient (a-Cronbach’s) of 0.76 for awareness items. The questionnaire covered the following data: participants’ socio-demographic data like age, gender, and monthly income. Second section covered participants’ dairy products intake with associated symptoms. Third part covered personal and family history of glucose intolerance disorder among the study participants. Awareness was assessed using multiple repose and mutually exclusive questions. The questionnaire was uploaded online using social media platforms by the researchers and their friends during the period from 1st August to 31st October 2021. All accessible and eligible population in the study setting were invited to fill the attached tool.

Data analysis

After data were extracted, it was revised, coded, and fed to statistical software IBM SPSS version 22 (SPSS, Inc., Chicago, IL). All statistical analysis was done using two tailed tests. P value less than 0.05 was statistically significant. For knowledge and awareness items, each correct answer was scored one point and total summation of the discrete scores of the different items was calculated. A patient with score less than 60% (0–10 points) of the total score was considered to have poor awareness while good awareness was considered if he had score of 60% (11 points or more) of the total or more. Descriptive analysis based on frequency and percent distribution was done for all variables including participants’ socio-demographic data, glucose intolerance complaint, knowing others with glucose intolerance disorder, having dairy products, and associated symptoms. Also, participants awareness regarding glucose intolerance, causes, disease nature, complications, and high-risk groups and source of their information were showed in frequency tables. Cross-tabulation was used to assess distribution of public awareness level according to their personal data, disease history, and source of information. Relations were tested using Pearson Chi-square test and exact probability test for small frequency distributions.

Results

A total of 1189 participants fulfilling the inclusion criteria completed the study questionnaire. Participants’ ages ranged from 18 to 58 years with mean age of 25.1 ± 12.9 years. Exact of 692 (58.2%) participants were females. As for educational level, 885 (74.4%) were university graduated and 245 (20.6%) had secondary level of education. Income was just sufficient among 830 (69.8%) participants and more than sufficient among 247 (20.8%). Exact of 544 (45.8%) told that they know about lactose intolerance disorder [Table 1].

Table 1

Socio-demographic data of study population, Saudi Arabia

Socio-demographic data	No	%
Age in years
<25 years	628	52.8%
25-45 years	419	35.2%
>45 years	142	11.9%
Gender
Male	497	41.8%
Female	692	58.2%
Educational level
Below secondary	59	5.0%
Secondary	245	20.6%
University/above	885	74.4%
Income
Less than sufficient	112	9.4%
Just sufficient	830	69.8%
More than sufficient	247	20.8%
Know about lactose intolerance disorder
Yes	544	45.8%
No	645	54.2%

Table 2 Lactose intolerance frequency and related practice among study participants, Saudi Arabia. Exact of 104 (8.7%) of the study participants reported that they had lactose intolerance disorder which started at the age of 11 to 20 years among 41 (39.4%) and at the age of 21 to 30 years among 36 (34.6%), while 18 (17.3%) had the disease during the first 10 years of their life. Also, 352 (29.6%) participants reported that they know someone who had the disorder who were first degree relative among 128 (36.5%) and second degree relative among 41 (11.7%), while 38 had third degree relative with the disorder (10.8%). As for participants’ dairy products intake, 811 (68.2%) reported that they consume dairy or its derivatives on a daily basis. Exact of 36.5% of them complained of Abdominal distention and gases, 22.8% complained of abdominal pain only, 12.1% had diarrheal attacks, and 12.7% had nausea and vomiting, while 53.7% had no symptoms.

Table 2

Lactose intolerance frequency and related practice among study participants, Saudi Arabia

Lactose intolerance data	No	%
Do you consume dairy or its derivatives on a daily basis?
Yes	811	68.2%
No	378	31.8%
If you consume dairy and dairy products, have you noticed any of the following symptoms
Abdominal distention and gases	434	36.5%
Abdominal pain	271	22.8%
Diarrhoea	144	12.1%
Nausea	108	9.1%
Vomiting	43	3.6%
No symptoms	639	53.7%
Do you have lactose intolerance disorder?
Yes	104	8.7%
No	423	35.6%
Do not know	662	55.7%
If yes, age at diagnosis (years) (n=104)
0-10	18	17.3%
11-20	41	39.4%
21-30	36	34.6%
31-40	9	8.7%
Do you know anyone who has lactose intolerance?
Yes	352	29.6%
No	837	70.4%
Degree of relation with that person (n=352)
First degree	128	36.5%
Second degree	41	11.7%
Third degree	38	10.8%
Not relative	184	52.4%

Table 3 Public awareness regarding lactose intolerance disorder in Saudi Arabia. Exact of 77.1% of the study participants know that lactose indolence disorder symptoms appear after eating dairy or its derivatives. As for metho to relieve symptoms in a person with lactose intolerance, 75.3% reported for avoiding dairy and its derivatives and use lactose-free alternatives. Only 24.8% of the participants know that lactose intolerance disorder may start after Gastrointestinal (GIT) disorders/infections. Exact of 70.4% of the population know that people with lactose intolerance need to take nutritional supplements, 79% know that people with lactose intolerance need to consume alternatives to lactose-containing products, and 53.6% reported that lactose-free dairy products lack the nutritional value found in dairy and dairy products. A total of 45.8% reported that leaky gut syndrome (diarrhoea and bloating) is caused by symptoms that occur with lactose intolerance and 39.4% know lactose intolerance is uncurable disease. Also, 89.1% of the study population know that the severity of lactose intolerance differs from person to person and 46.9% know that milk allergy and lactose intolerance are not the same. Exact of 76.7% of the participants reported that it is possible to get lactose intolerance if your parents are not affected, and 68.6% know it is possible for a person to suddenly had lactose intolerant. As for disease complications, 38.2% reported for Ca and vitamin D deficiency, 33.1% reported for osteoporosis, and 38.7% know about GIT complications. As for testing for lactose intolerance disorder, stool acidity assessment was known for 25.5% of the participants. Considering the highly risk groups, Asians were known for 58.3% of the study participants followed by Africans (25.1%).

Table 3

Public awareness regarding lactose intolerance disorder in Saudi Arabia

Awareness items		No	%
In your opinion, when do symptoms usually occur?	After eating dairy or its derivatives.	917	77.1%
	At daytime	127	10.7%
	At night	272	22.9%
How to relieve symptoms in a person with lactose intolerance?	Avoid dairy and its derivatives and use lactose-free alternatives	895	75.3%
	Physician consultation	354	29.8%
	Using analgesics	150	12.6%
What are the causes of lactose intolerance disorder?	After GIT disorders/infections	295	24.8%
	After GIT surgery’	52	4.4%
	After using some drugs	51	4.3%
	Dont know	791	66.5%
People with lactose intolerance need to take nutritional supplements	Yes	837	70.4%
	No	352	29.6%
People with lactose intolerance need to consume alternatives to lactose-containing products?	Yes	939	79.0%
	No	250	21.0%
Can lactose-free dairy products lack the nutritional value found in dairy and dairy products?	Yes	637	53.6%
	No	552	46.4%
Did you know that leaky gut syndrome (diarrhoea and bloating) is caused by symptoms that occur with lactose intolerance?	Yes	544	45.8%
	No	645	54.2%
Do you think lactose intolerance is curable?	Yes	720	60.6%
	No	469	39.4%
Does the severity of lactose intolerance differ from person to person?	Yes	1059	89.1%
	No	130	10.9%
Do you think milk allergy and lactose intolerance are the same?	Yes	631	53.1%
	No	558	46.9%
Is it possible to get lactose intolerance if your parents are not affected?	Yes	912	76.7%
	No	277	23.3%
Is it possible for a person to suddenly had lactose intolerant?	Yes	816	68.6%
	No	373	31.4%
Complications of lactose intolerance disorder?	Ca & vitamin D deficiency	454	38.2%
	Osteoporosis	393	33.1%
	GIT complications	460	38.7%
	Reduced weight	225	18.9%
	Neurological disorders	231	19.4%
	Dont know	416	35.0%
How can lactose intolerance be tested?	Stool acidity assessment	303	25.5%
	Blood glucose level assessment	257	21.6%
	Breath hydrogenation test	141	11.9%
	Dont know	641	53.9%
The most susceptible ethnic group?	Asians	693	58.3%
	Africans	299	25.1%
	Europeans	404	34.0%
	Latins	212	17.8%

Figure 1 Overall awareness level of the general population regarding lactose intolerance disorder in Saudi Arabia. Exact of 452 (38%) participants had good awareness level regarding the disorder while 737 (62%) had poor awareness.

Figure 1

Overall awareness level of the general population regarding lactose intolerance disorder in Saudi Arabia

Figure 2 Source of information regarding lactose intolerance disorder among population, Saudi Arabia. The most reported source of information was internet (28.8%), followed by relatives and friends (17.6%), physicians (12.4%), books (9.3%), academic study (6.1%), and newspapers (3.2%). Exact of 48.1% had no specific source for the disease.

Figure 2

Source of information regarding lactose intolerance disorder among population, Saudi Arabia

Table 4 Distribution of public awareness regarding lactose intolerance by their bio-demographic data. Exact of 44.6% of participants aged less than 25 years had good awareness level compared with 24.6% of old age group with recorded statistical significance (P =0.001). Also, 42.6% of females had good knowledge level versus 31.6% of males (P =0.001). Good knowledge was significantly higher among university graduated participants (39.2%) than among those who had below secondary education (23.7%; P =.048). Also, 51.8% who heard about the disorder had good awareness compared with 26.4% of those who did not (P =.001). Exact of 54.8% of participants had lactose intolerance disorder and had good awareness about the disease compared with 30.1% of those who do not know (P =.001). Also, 53.7% of participants who know others with the disease had good awareness regarding the disease compared with 31.4% of those who did not (P =.001). The highest awareness level was detected among participants who had their information from physicians (65.3%) compared with 60.3% who reported academic study and 51.4% of those who reported for books but 27.6% of those who had no source showed good awareness (P =.001).

Table 4

Distribution of public awareness regarding lactose intolerance by their bio-demographic data

Factors	Awareness level				P
	Poor (0-10)		Good (11-18)
	No	%	No	%
Age in years					0.001*
<25 years	348	55.4%	280	44.6%
25-45 years	282	67.3%	137	32.7%
>45 years	107	75.4%	35	24.6%
Gender					0.001*
Male	340	68.4%	157	31.6%
Female	397	57.4%	295	42.6%
Educational level					0.048*
Below secondary	45	76.3%	14	23.7%
Secondary	154	62.9%	91	37.1%
University/above	538	60.8%	347	39.2%
Know about lactose intolerance disorder					0.001*
Yes	262	48.2%	282	51.8%
No	475	73.6%	170	26.4%
Do you have lactose intolerance disorder?					0.001*
Yes	47	45.2%	57	54.8%
No	227	53.7%	196	46.3%
Do not know	463	69.9%	199	30.1%
Do you know anyone who has lactose intolerance?					0.001*
Yes	163	46.3%	189	53.7%
No	574	68.6%	263	31.4%
Source of information					0.001*
None	414	72.4%	158	27.6%
Internet	170	49.7%	172	50.3%
Physicians	51	34.7%	96	65.3%
Academic study	29	39.7%	44	60.3%
Books	54	48.6%	57	51.4%
Relatives/friends	113	54.1%	96	45.9%
Newspapers	26	68.4%	12	31.6%

P: Pearson χ2 test, $ Exact probability test. *P <0.05 (significant)

Discussion

Lactose intolerance is a GIT disorder detected among more than 65% of the human population. An intolerance to lactose is featured by the incapability to digest the lactose sugar in milk and dairy products causing a state of stomach pains or discomfort.[151617] As for public issue, lactose intolerance disorder usually affected by lifestyles with increased rates associated with higher liberties and lower sunlight exposure and, thus, lower vitamin D.[1819] Intestinal flora is quite different from person to person, so it is difficult to identify a single, generalizable intestinal flora composition, and to define a specific healthy one. Nevertheless, it is a feature that the best intestinal flora shows a high degree of stable species variety.[20] So, it is vital to improve public awareness of lactose intolerance. With the main knowledge about symptoms and use of lactose free diet, LI can be significantly decreased. This study was conducted to assess public awareness regarding lactose intolerance and to study condition after consuming dairy products and if people can relate the mentioned symptoms to the consumption of milk products. Awareness of LI and the available alternatives to milk can help people to reduce their associated symptoms.

This study’s results revealed that more than one third (38%) of the study participants had good knowledge regarding lactose intolerance. As for disease nature, more than three quarters (77.1%) of the study participants know that lactose indolence disorder symptoms appear after eating dairy or its derivatives. Also, half of the participants (53.6%) correctly know that lactose-free dairy products lack the nutritional value found in dairy and dairy products. Less than half of the study respondents (45.8%) reported that leaky gut syndrome (diarrhoea and bloating) is caused by symptoms that occur with lactose intolerance, and more than one third (39.4%) correctly reported lactose intolerance is uncurable disease. Also, vast majority of the study group (89.1%) correctly know that the severity of lactose intolerance differs from person to person, and 46.9% know that milk allergy and lactose intolerance are not the same. Considering metho to relieve symptoms in a person with lactose intolerance, about three quarters correctly reported for avoiding dairy and its derivatives and use lactose-free alternatives. About risk factors more than three quarters (76.7%) of the participants know that it is possible to get lactose intolerance if your parents are not affected, and two thirds (68.6%) agreed that it is possible for a person to suddenly had lactose intolerant. Only one quarter (24.8%) of the participants know that lactose intolerance disorder may start after GIT disorders/infections. On the other hand, less than the quarters of the study population know that people with lactose intolerance need to take nutritional supplements, and more than three quarters (79%) know that people with lactose intolerance need to consume alternatives to lactose-containing products. Considering complications, 38.2% reported for Ca and vitamin D deficiency, 33.1% reported for osteoporosis, and 38.7% know about GIT complications. As for testing for lactose intolerance disorder, stool acidity assessment was known for 25.5% of the participants. With regard to the highly risk groups, Asians were known for 58.3% of the study participants followed by Africans (25.1%). Public awareness was significantly higher among young aged participants who mostly had higher level of education, and among females, persons with personal or family history of lactose intolerance disorder. Also, higher awareness was reported among participants who had their information from physician who were not the most reported source as internet was the main source of public information while nearly half of them had no specific source of information. Similar level of awareness was detected among Indian population by Diandra et al.[21] who found that 71.5% of the respondents knew about lactose intolerance. Also, 78.7% of the respondents did not experience the associated symptoms; 21.3% of those who observed symptoms observed bloating apart from other listed symptoms. Also, 59.7% of the respondents used alternative for dairy products to reduce symptoms. Lacose indolence awareness among study patients was not high with frequent intake of dairy products among the study respondents with reported GIT symptoms.

Conclusions and Recommendations

In conclusion, this study revealed that nearly one out of each three persons on Saudi Arabia is knowledgeable regarding lactose intolerance disorder and its related factors and relieving factors. Dairy products use in daily basis was reported among two thirds of the study population with abdominal distention and abdominal pain was the main accompanying symptoms. Public awareness regarding lactose intolerance and the availability of alternative lactose free diet should be improved to reduce the disease frequency and improving public quality of life. This can be achieved through health education campaigns, posters, mass media, and social media. Physicians especially those at primary health care centers should pay more effort to improve public awareness regarding GIT health and dietary life style.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.