Dairy Consumption: Effects on Nutrient
Status and Risk of Chronic Disease
Beth H. Rice, PhD, Director, Scientific Affairs
June, 2013
Established under the leadership of America's dairy farmers with a
commitment to nutrition, product and sustainability research.
A 501(c)(3) non-profit organization that works with and through
industry, academic, government and commercial partners to drive pre-
competitive research on behalf of the Innovation Center for U.S.
Dairy®, the National Dairy Council® and other partners.
Beth H. Rice, PhD, Director, Scientific Affairs
+1-(631)-804-4274
www.usdairy.com/dairyresearchinstitute
1
Dairy Research Institute
2
Nutrition is defined as food necessary for survival
Giuseppe Arcimboldo, 1590, Holy Roman Emperor Rudolf II
3
Americans are overweight and undernourished
Centers for Disease Control and Prevention
Dietary Guidelines for Americans 2010
4
Dairy’s place in the diet of the overweight and
undernourished
Choosemyplate.gov
5
Dairy and nutrient status
Many Americans fall short on nutrient intakes
6
0 10 20 30 40 50 60 70 80
seleniumcopper
zinciron
magnesiumphosphorus
folatevitamin B-12
vitamin B-6niacin
riboflavinthiamin
vitamin Evitamin Cvitamin A
calciumvitamin D
% below the Estimated Average Requirement
% of Americans with nutrient intakes from food and supplements below the Estimated Average Requirement
Adapted from Fulgoni et al., J Nutr. (2011) 1847 - 1854
Just 2.5% of Americans have intakes from food and supplements
above the Adequate Intake for potassium
Dairy contributes nutrients to the American diet
10
58
51
28
16 13
26 25 28
18 16
11 14
26
NHANES (2003-2006), Ages 2+ yr
7
Percent of calories & nutrients from dairy
Dairy contributes nutrients to the global diet
8
Nutrients Aus Bel Can Den Fra Ire Neth UK
Calories 11 13 11 7
Fat 14 16 14 25 15
Vitamin A 10 20 12 22 17 7-8 10
Vitamin D 50 12 7 9 7-9
Vitamin B12 30 35 19 30-37 35
Riboflavin 20 20 42 33 46-50 30
Calcium 50 54 50 57 52 39 69-75 40
Magnesium 10 15 15 11 17-18 10
Phosphorus 20 20 35 25 20 20
Potassium 10 15 17 12 10
% contributed from dairy to total diet
Global Dairy Platform, International Dairy Federation
Recommended dairy servings
9
Country Recommendation
United States 3 cups low-fat and fat-free milk, cheese and yogurt for
people 9+ years
Denmark Select low-fat and fat-free milk and milk products
Belgium 3 - 4 glasses of milk or milk products (~ 450 – 600 ml total)
and 1 to 2 slices of cheese (~20 - 40 g total) depending on
age, preferably low-fat
The Netherlands 400 – 650 mL of milk and milk products and 20 – 30 g of
cheese depending on age
10
Gaps between current and recommended intakes: US
Usual intakes as % of recommendations
2010 Dietary Guidelines
for Americans
“Choose foods that provide more
potassium, dietary fiber,
calcium, and vitamin D.
“These foods include
vegetables, fruits, whole grains,
and milk and milk products.”
GOAL
US Department of Agriculture and US Department of Health and Human
Services. Dietary Guidelines for Americans, 2010. 7th Edition, Washington,
DC: US Government Printing Office, December 2010
11
Removing dairy from the diet would widen nutrient gaps
1.7 SERVINGS
Modeled intakes - no dairy
GOAL
Modeled intakes – no dairy
33%
10%
45%
2010 Dietary Guidelines
for Americans
“Choose foods that provide more
potassium, dietary fiber,
calcium, and vitamin D.
“These foods include
vegetables, fruits, whole grains,
and milk and milk products.”
Adapted from Fulgoni et al., Nutr Res (2011) 759 - 765
Adding a serving of dairy would help close nutrient gaps
12
GOAL
Modeled intakes – add one dairy serving
GOAL
Modeled intakes – add one dairy serving
2010 Dietary Guidelines
for Americans
“Choose foods that provide more
potassium, dietary fiber,
calcium, and vitamin D.
“These foods include
vegetables, fruits, whole grains,
and milk and milk products.”
Adapted from Fulgoni et al., Nutr Res (2011) 759 - 765
13
Gaps between current and recommended intakes:
worldwide
Global Dairy Platform, International Dairy Federation
14
Dairy offers a high nutrient value for its monetary cost
Adapted from Drewnowski , Am J Clin Nutr (2010) 1181 - 1188
15
Dairy and cardiovascular disease
CVD
31%
NCD
33%
Injuries
9% Communicable,
maternal, perinatal,
and nutritional
conditions 31%
16
CVD mortality around the world
WHO, 2011, Global Atlas on CVD Prevention and Control
“Moderate evidence also indicates that intake of
milk and milk products is associated with a reduced
risk of cardiovascular disease and type 2 diabetes
and with lower blood pressure in adults”
17
Dietary Guidelines point to an association between dairy
consumption and lower risk for chronic disease
US Department of Agriculture and US Department of Health and Human
Services. Dietary Guidelines for Americans, 2010. 7th Edition, Washington,
DC: US Government Printing Office, December 2010
18
Recent evidence shows that dairy intake is associated
with lower CVD risk
The intake of total dairy was
associated with lower risks for
several CVD outcomes
Some, but not all, of these
trials were completed before
low-fat dairy products were
commonly consumed
More observational evidence
on full-fat dairy is needed
Elwood et al. Lipids (2010) 925 939
19
More evidence since the 2010 DGAC
Study Endpoint Outcomes
Bonthuis et al
(2010) CVD
• Overall intake of dairy products was not associated with mortality, while full-fat dairy intake
was associated with reduced CVD mortality
Warensjö et al
(2010) CVD
• Circulating fatty acids from dairy were associated with a lower risk of developing a first
myocardial infarction, especially in women.
Soedamah-Muthu et
al (2011) CVD
• Meta-analysis concludes milk intake is not associated with total mortality but may be
inversely associated with overall CVD risk
Sonestedt et al
(2011) CVD
• Intake of fermented milk reduced risk of CVD
• Cheese intake was significantly associated with decreased CVD risk in women
Dalmeijer et al
(2012) CVD
• High intakes of total and low-fat dairy were associated with a lower risk of CHD among
participants without hypertension
• Fermented dairy was associated with a reduced risk of stroke.
Larsson et al
(2012) CVD • Low-fat dairy consumption was inversely associated with the risk of stroke.
de Oliveira Otto et al
(2012) CVD • A higher intake of dairy saturated fat was associated with lower CVD risk.
Avalos et al
(2012) CVD
• Higher risk in women consuming low-fat cheese and non-fat milk
• Trend for reduced risk in women with full-fat cheese
Patterson et al
(2013) CVD
• Total cheese was inversely associated with risk of MI in women.
• Butter used on bread but was positively associated with MI, but butter used in cooking was
not associated with MI.
• No association with other dairy foods and no difference between low-fat and full-fat.
Louie et al
(2013) CVD
• For total dairy intake, there was a reduction in risk of CVD seen in tertile 2, and for CHD
both tertile 2 and tertile 3 were associated with a reduced risk; however there were no
linear trends between total dairy consumption and these outcomes.
20
Milk inversely associated with CVD in dose-response
meta-analysis of prospective cohort studies
per 200 mL/d
Adapted from Soedamah-Muthu et al., Am J Clin Nutr (2011) 158 - 171
21
Cheese consumption does not detrimentally impact
blood lipids in randomized dietary intervention
Run-In Cheese Butter Run-In Cheese Butter
Run-In Cheese Butter
Adapted from Hjerpsted et al., Am J Clin Nutr (2011) 1479 - 1484
22
Dairy and blood pressure
23
More evidence since the 2010 DGAC
Study Endpoint Outcomes
van Meijl and
Mensink (2011)
Blood
Pressure • Dairy reduced systolic blood pressure; trend for a reduction in diastolic blood pressure
Ralston et al. (2012) Blood
Pressure
• Meta-analysis supports the inverse association between low-fat dairy foods and fluid dairy
foods and risk of elevated blood pressure
Soedamah-Muthu et
al. (2012)
Blood
Pressure
• Dose-response meta-analysis showing that total dairy, low-fat dairy, and milk were
associated with reduced risk of hypertension.
• Yogurt, cheese, full-fat dairy, and fermented dairy were neutral
Livingstone et al.
(2013)
Blood
Pressure
• Augmentation index was 1.8% lower in subjects in the highest quartiles of dairy product
intake compared with the lowest
• In the highest group of milk consumption, systolic blood pressure was 10.4 mm Hg lower
than in non-milk consumers after a 22.8-year follow-up
• Across increasing groups of milk intake glucose was lower and across increasing total
dairy product intake triglycerides were lower
24
Total and low-fat dairy inversely associated with risk of elevated
blood pressure in meta-analysis of prospective cohort studies
Adapted from Ralston et al., J Hum Hypertens (2012) 3 - 13
Full-fat dairy had no association with risk of EBP
Cheese had no association with risk of EBP
Fluid dairy inversely association with risk of EBP
25
Dairy’s effect on risk of elevated blood pressure may be
driven by fluid milk
Adapted from Ralston et al., J Hum Hypertens (2012) 3 - 13
Total dairy, low-fat dairy, and
milk were inversely and linearly
associated with a lower risk of
hypertension
Full-fat dairy, total fermented
dairy, yogurt, and cheese were
not significantly associated with
incidence of hypertension
Clinical studies to test an
independent effect of dairy on
blood pressure are warranted
26
Dairy inversely associated with risk of hypertension in
meta-analysis of prospective cohort studies
Adapted from Sodamah-Muthu et al., J Hum Hypertens (2012) 1131 - 1137
27
Dairy and type 2 diabetes
28
Diabetes prevalence and public health burden
Percent 0 - 6.5
6.6 - 8.0
8.1 - 9.4
9.5 - 11.1
> 11.2
2004
2009
Diagnosed diabetes among adults aged ≥ 20 yrs
25 M = number of people in the
United States affected by diabetes,
2010
11.3% of all people ≥ 20yrs
26.9% of all people ≥ 65yrs
79 M = number of people in the
United States estimated to have pre-
diabetes
$174 B = estimated total diabetes
medical costs in the United States,
2007
Centers for Disease Control and Prevention
29
Aggressive lifestyle intervention can slow progression
to type 2 diabetes
Reduction in the Incidence of Type 2 Diabetes With Lifestyle Intervention or Metformin
DPP Research Group, N Engl J Med (2002) 393 - 403
More evidence since the 2010 DGAC
30
Study Endpoint Outcomes
Mozaffarian et al.
(2010) T2D
• Circulating trans-palmitoleate, a biomarker of dairy fat intake, is associated with lower
insulin resistance, presence of atherogenic dyslipidemia, and incident diabetes.
Tong et al.
(2011) T2D
• Meta-analysis reports low-fat dairy and yogurt consumption were associated with
significant reductions in type 2 diabetes risk
• An additional serving per day of low-fat dairy foods was associated with a 10% decrease in
type 2 diabetes risk
Malik et al.
(2011) T2D
• Dairy product intake of women during high school was significantly inversely associated
with type 2 diabetes risk in adulthood
Margolis et al.
(2011) T2D
• Low-fat dairy product consumption was inversely associated with the risk of type 2 diabetes
• High yogurt consumption was associated with a significant decrease in diabetes risk
Granthem et al.
(2012) T2D
• Dairy product consumption was inversely associated with the risk of type 2 diabetes in
men, with a similar non-significant trend in women
Sluijs et al.
(2012) T2D
• A higher combined intake of fermented dairy products (cheese, yogurt, and fermented milk)
was inversely associated with type 2 diabetes
• No association between total dairy product intake and diabetes risk
Struijk et al.
(2012) T2D
• Cheese intake was associated with improved glucose tolerance
• Fermented dairy intake was associated with improved fasting glucose and HbA(1c)
• No association with incident type 2 diabetes
Mozaffarian et al.
(2013) T2D
• Circulating trans-palmitoleate, a biomarker of dairy fat intake, is associated with higher LDL
cholesterol but also with lower triglycerides, fasting insulin, blood pressure, and incident
diabetes in a multiethnic US cohort
31
Dairy inversely related to type 2 diabetes in meta-
analysis of prospective cohort studies
Tong et al., Eur J Clin Nutr (2011) 1027 - 1031
An additional serving per day
of low-fat dairy foods was
associated with a 10%
decrease in type 2 diabetes
risk
Low-fat dairy (-18%) and
yogurt consumption (-17%)
were associated with
significant reductions in type
2 diabetes risk
Those with high dairy intake in
high school had a 38% lower
risk for developing type 2
diabetes as adults
Need to sustain dairy intake in
adulthood to maximize risk
reduction
32
Higher dairy intake is associated with lower incidence
of type 2 diabetes
High (3.8)
Med (2.5)Low (1.5)
0
0,2
0,4
0,6
0,8
1
1,2
Low(1.3)
Med(2.3)
High(3.6)
Current
Re
lati
ve
Ris
k ref
Adapted from Malik et al. Am J Clin Nutr (2011) 854 - 861
33
Adequate dairy lowers biomarkers for pre-diabetes
-6
-4
-2
0
2
4
6
Low Dairy Adequate Dairy
Fa
sti
ng
In
su
lin
(µ
U/m
L)
(< 0.5 daily serv) (3.5 daily serv)
Adapted from Stancliffe et al., Am J Clin Nutr (2011) 422 - 430
34
Higher levels of a dairy specific fatty acid are associated
with a lower incidence of type 2 diabetes
0
0,2
0,4
0,6
0,8
1
1,2
1 2 3 4 5
Quintiles of trans-Palmitoleic Acid in Blood
Rela
tive R
isk o
f In
cid
ent
Dia
bete
s
Adapted from Mozaffarian et al. Ann Intern Med (2010) 790 - 800
French Data from the Epidemiological Study on the Insulin Resistance
Syndrome (DESIR) cohort (n = 3,435) was analyzed to assess the
influence of dairy products on 9-year incident metabolic syndrome,
impaired fasting glucose and/or type 2 diabetes
Dairy product consumption (w/o cheese) and calcium intake were
inversely associated with incident metabolic syndrome and type 2
diabetes
Cheese intake was inversely associated with metabolic syndrome
All three parameters (dairy consumption, calcium intake, and cheese intake) were
associated lower diastolic blood pressure, and with a lower BMI gain
Higher cheese intake and calcium intake were associated with a lower increase in
waist circumference and lower triglyceride levels
35
Cheese intake inversely associated with metabolic
syndrome in DESIR cohort
Fumeron et al. Diabetes Care (2011) 813 - 817
Data from 7,815 men and 9,685 women enrolled in the Oslo Health
Study were analyzed to determine a relationship between frequency
of cheese intake and metabolic syndrome
Cheese intake was associated with reduced risk for metabolic
syndrome, fewer metabolic syndrome risk factors, and improvement in
individual metabolic syndrome components
Relationship prevailed after controlling for sex, age, time since last meal, intake of
fruit/berries, fruit juice, fatty fish, coffee, alcohol, smoking, physical activity,
education, and birthplace
Cheese intake was associated with a lower risk for CVD and type 2 diabetes
Higher frequency of cheese intake was also associated with a significantly lower
body mass index in all but the oldest women (75-76 years)
36
Cheese intake inversely associated with metabolic
syndrome in Oslo Health Study
Høstmark and Tomten. J Am Coll Nutr (2011) 182 - 190
37
Dairy and bone
38
Bone mass declines after age 30
nlm.nih.gov
39
7 clinical trials published since the Dietary Guidelines for Americans
2010 indicate the dairy consumption improves bone health in women
“Moderate evidence shows that intake of milk and milk products is
linked to improved bone health, especially in children and
adolescents.”
Dairy contributes to bone health throughout the
lifespan
US Department of Agriculture and US Department of Health and Human
Services. Dietary Guidelines for Americans, 2010. 7th Edition, Washington,
DC: US Government Printing Office, December 2010
40
Dairy and weight
41
Certain foods are associated with weight change in
adults
Dairy
Weight change associated with each increased
daily serving, per 4-year period (lbs)
Three large cohorts • Nurses Health Study
• Nurses Health Study II
• Health Professionals Follow-up Study
Mozaffarian et al., New Eng J Med (2011) 2392 - 2404
42
Dairy may help contribute to lower weight in adults in
meta-analysis of randomized controlled clinical trials
Abargouei et al., Int J Obesity (2012) 1485 - 1493
43
Dairy may help contribute to lower weight in adults in
meta-analysis of randomized controlled clinical trials
Chen et al., Am J Clin Nutr (2012) 735 - 747
Dairy foods, including milk, cheese and yogurt, contribute essential
nutrients to the diet
Consuming low-fat and fat-free dairy foods is associated with:
better nutrient status
reduced risk of cardiovascular disease and type 2 diabetes in adults
lower blood pressure in adults
bone health throughout the lifespan
healthy weight
44
Dairy is a key contributor to a healthy diet
45
End of deck
Three of the top 10 sources of calories and SFA (beef, milk and cheese)
contribute 46.3% of the calcium, 49.5% of the vitamin D, 42.3% of the
vitamin B12 as well as other essential nutrients to the American diet
Conversely, foods categorized as desserts, snacks, or beverages, contribute
25.5% of total calories, 83% of added sugar intake, and provide little or no
nutritional value.
46
Don’t throw baby out with the bath water