Research suggests that eating yogurt can modify the mouth’s microbiome and is associated with improved oral health, helping to protect against tooth decay and gum disease – the main causes of tooth loss.

Regular yogurt consumption may reduce the risk of tooth decay and inflammatory gum disease

Adults who eat yogurt every day have a lower risk of tooth loss resulting from gum disease, compared with those who don’t eat any yogurt.

Eating yogurt daily has also been associated with a reduced risk of tooth decay among children and teenagers, compared with not eating yogurt. Several studies have shown that daily consumption of dairy products, including yogurt, is associated with improved oral health compared with less frequent consumption:

• One study showed that adults who ate or drank more than six servings of dairy food (including milk and yogurt) per week had a 24% lower prevalence of gum disease than those who didn’t consume any dairy food. This difference was reduced to just 9% for infrequent consumption of dairy food (one serving per week or less).
• Authors of one study recommended daily consumption of yogurt to improve oral health after they found that adults who ate yogurt daily were 76% less likely to have gum disease than those who ate yogurt less than once a week.
• Another study reported greater oral health improvements in children who drank Lactobacillus probiotic milk every day, compared with three times a week – these benefits remained for at least 6 months after discontinuation.

Dairy products have several protective effects against tooth decay

According to evidence from both interventional and observational studies, consuming dairy products may be associated with a reduced risk of tooth decay due to several different protective effects:

• Lactose in milk has lower potential for causing tooth decay than other dietary sugars as it is not fermented to acidic products in the mouth.
• Calcium and phosphate in milk help prevent the decay of tooth enamel and may even support remineralisation of tooth enamel.
• The proteins and fats in milk may also reduce the ability of plaque to stick to tooth enamel and produce acids. It is likely that the protective potential of plain unsweetened yogurt is similar to that of milk.

“Eating yogurt every day may contribute to improved oral health by modifying the mouth’s microbiome, reducing the risk of developing tooth decay and gum disease in both adults and children.”- Professor Sharon Donovan

The probiotic content of some yogurts may add to their oral health benefits

Several randomised controlled trials have demonstrated that yogurts containing added Bifidobacterium or Lactobacillus probiotic cultures are effective antibacterial agents against plaque-causing Streptococcus mutans bacteria.

Such probiotic yogurts were shown to reduce levels of Streptococcus mutans bacteria in the saliva and dental plaque of both adults and children.

In one study, probiotic yogurt also increased salivary pH, reducing the acidity of saliva by diminishing the acid production ability of Streptococcus mutans.

Laboratory cultures have also shown that Lactobacillus probiotic yogurt can inhibit the growth and adhesion of Streptococcus mutans bacteria.

Randomised controlled trials have shown that eating yogurt containing added Bifidobacterium or Lactobacillus probiotic cultures is associated withreductions in several markers of gum inflammation

People who ate probiotic-containing yogurts experienced greater reductions in plaque formation, gum inflammation, probing depth, bleeding on probing, and inflammatory fluids or markers, compared with those who ate non-probiotic containing yogurt.

These oral health benefits may be achieved through modifying the oral microbiome

Studies in adults and children suggest that consumption of dairy products containing added probiotics, including yogurt containing added Bifidobacterium or Lactobacillus probiotic strains, may help prevent tooth decay through modification of the oral microbiome.

Evidence suggests that these benefits are achieved due to the ability of the live bacteria in probiotic containing dairy products to modify the composition of the mouth’s microbiome, and so reduce the decay-causing bacteria that can lead to oral disease.

The characteristics of individual dairy products may also have an important role – the lactic acid bacteria starter cultures used to make fermented dairy products, such as yogurt, may also help to reduce tooth decay-causing bacteria.

For more information, check the complete publication “Yogurt from science to health”

References:

• Ma J, Furuta M, Uchida K, et al. Yogurt product intake and reduction of tooth loss risk in a Japanese community. J Clin Periodontol. 2022;49:345–52.

• Wang J, Jin G, Gu K, et al. Association between milk and dairy product intake and the risk of dental caries in children and adolescents: NHANES 2011-2016. Asia Pac J Clin Nutr. 2021;30:283–90.

• Lee K, Kim J. Dairy Food Consumption is Inversely Associated with the Prevalence of Periodontal Disease in Korean Adults. Nutrients. 2019;11:1035.

• Lee HJ, Kim SJ, Park YS, et al. Association between semi-solid yogurt intake and periodontitis in Korean adults. J Periodontal Implant Sci. 2019;49:206–14.

• Manmontri C, Nirunsittirat A, Piwat S, et al. Reduction of Streptococcus mutans by probiotic milk: a multicenter randomized controlled trial. Clin Oral Investig. 2020;24:2363–74.

• Woodward M, Rugg-Gunn AJ. Chapter 8: Milk, Yoghurts and Dental Caries. Monogr Oral Sci. 2020;28:77–90.

• Gardner E. Alternative sugars: Lactose (milk sugar). Br Dent J. 2017;223:801.

•  Shaalan O, Gad HMA, Riad MI, et al. Comparison of Antibacterial Effect of Probiotic Yogurt and Xylitol-Containing Chewing Gum in Geriatric Patients: A Randomized Controlled Clinical Trial. Acta Stomatol Croat. 2021;55:380–9.

• Megha S, Shalini G, Varsha SA, et al. Effect of Short-Term Placebo-Controlled Consumption of Probiotic Yoghurt and Indian Curd on the Streptococcus mutans Level in Children Undergoing Fixed Interceptive Orthodontic Therapy. Turk J Orthod. 2019;32:16–21.

• Bafna HP, Ajithkrishnan CG, Kalantharakath T, et al. Effect of Short-term Consumption of Amul Probiotic Yogurt Containing Lactobacillus acidophilus La5 and Bifidobacterium Lactis Bb12 on Salivary Streptococcus mutans Count in High Caries Risk Individuals. Int J Appl Basic Med Res. 2018; 8:111–5.

• Ghasemi E, Mazaheri R, Tahmourespour A. Effect of Probiotic Yogurt and Xylitol-Containing Chewing Gums on Salivary S Mutans Count. J Clin Pediatr Dent. 2017;41:257–63.

• Wu CY, He SJ, Mar K, et al. Inhibition of Streptococcus mutans by a commercial yogurt drink. J Dent Sci. 2019;14:198–205.

• Yuki O, Furutani C, Mizota Y, et al. Effect of bovine milk fermented with Lactobacillus rhamnosus L8020 on periodontal disease in individuals with intellectual disability: a randomized clinical trial. J Appl Oral Sci. 2019;27:e20180564.

• Kuru BE, Laleman I, Yalnızoğlu T, et al. The Influence of a Bifidobacterium animalis Probiotic on Gingival Health: A Randomized Controlled Clinical Trial. J Periodontol. 2017;88:1115–23.

• Farias da Cruz M, Baraúna Magno M, Alves Jural L, et al. Probiotics and dairy products in dentistry: A bibliometric and critical review of randomized clinical trials. Food Res Int. 2022;157:111228.

• Nadelman P, Baraúna Magno M, Masterson D, et al. Are dairy products containing probiotics beneficial for oral health? A systematic review and meta-analysis. Clin Oral Investig. 2018;22:2763–85.

• Zare Javid A, Amerian E, Basir L, et al. Effects of the Consumption of Probiotic Yogurt Containing Bifidobacterium lactis Bb12 on the Levels of Streptococcus mutans and Lactobacilli in Saliva of Students with Initial Stages of Dental Caries: A Double-Blind Randomized Controlled Trial. Caries Res. 2020;54:68–74.

• Sarmento EG, Cesar DE, Martins ML, et al. Effect of probiotic bacteria in composition of children’s saliva. Food Res Int. 2019;116:1282–8

In March 2024, the U.S. Food and Drug Administration (FDA) approved a qualified health claim regarding the consumption of yogurt and its association with a reduced risk of type 2 diabetes (T2D). On June 29, 2024, a conference organized as part of the Nutrition 2024 Congress in Chicago revisited this announcement. It provided an opportunity for Christopher J. Cifelli (NDC) and Wendy Reinhardt Kapsak (IFIC)  to elaborate on the scientific basis of this claim and discuss its potential implications.

The health burden of Type 2 diabetes

In the United States, 38.4 million people have diabetes, which represents 11.6% of the population. Additionally, it is estimated that 97.6 million adults have pre-diabetes, putting them at greater risk of developing type 2 diabetes (T2D). Over the past 20 years, the number of adults diagnosed with diabetes has more than doubled.

However, adopting healthy lifestyle choices can help reduce the risk of T2D and lower public health costs:

• Excess body weight is a significant risk factor for T2D. Maintaining a healthy weight can reduce the risk of T2D and many other chronic diseases.
• Regular exercise helps manage blood sugar levels and lowers the risk of heart disease and other complications.
• A healthy diet forms a crucial part of the foundation for T2D prevention, treatment, and management.

Yogurt as part of a balanced diet: specific benefits for T2D

Yogurt offers specific benefits for type 2 diabetes (T2D) when included as part of a balanced diet. Four meta-analyses have consistently reported an association between yogurt consumption and a reduced risk of T2D (2-5).

The inverse association between yogurt consumption and T2D risk has been observed in populations across North America, Europe, the UK, Australia, and Japan. A meta-analysis of 14 studies, encompassing 483,090 individuals (with 32,896 T2D cases), found a 7% reduction in the risk of T2D for every 50 g (approximately 2 ounces) increase in daily yogurt consumption.

Evaluating the association between yogurt intake and diabetes-related parameters

In addition to the four meta-analyses, extensive data supports the role of yogurt in reducing the risk of type 2 diabetes (T2D). The FDA’s qualified health claim is based on robust methodology, and the association between yogurt intake and diabetes-related parameters was evaluated through a comprehensive literature search of 140 publications. Many articles were excluded for the following reasons:

• Background materials (reviews, meta-analyses, reports),
• Lack of assessment of yogurt’s effect on T2D-related parameters,
• Absence of scientific conclusions.

Ultimately, 28 observational studies, encompassing 860,000 subjects from 27 cohorts across 10 different countries, were included in the final analysis. These studies allowed for scientific conclusions to be drawn. Among these:

• Six high-quality methodological studies on prospective cohorts in the U.S. or Spain found an inverse relationship between yogurt consumption and the risk of T2D (3,6-10).
• Three high-quality studies examined changes in yogurt intake and reported a reduced risk of T2D (11-13).
• Twelve studies of lower methodological quality showed positive but inconsistent findings or varying results.

No statistically significant association was found between yogurt intake or changes in yogurt intake and a reduced risk of type 2 diabetes among the six studies with high methodological quality.

Based on this detailed analysis, credible scientific evidence indicates a statistically significant association between yogurt consumption and a reduced risk of type 2 diabetes. This association pertains to yogurt as a whole food rather than any single nutrient or compound within yogurt, regardless of its fat or sugar content.

How might yogurt reduce T2D risk?

Several mechanisms may explain the association between yogurt consumption and a reduced risk of type 2 diabetes (T2D):

• People who consume yogurt are less likely to have unhealthy lifestyles that are linked to an increased risk of T2D (15).
• Yogurt is a low glycemic index food, meaning it does not cause a significant spike in blood glucose levels after a meal.
• Chronic systemic inflammation may contribute to many noncommunicable diseases, including diabetes, and recent evidence suggests that regular yogurt consumption may have an anti-inflammatory effect (16,17).
• Live bacteria in yogurt can improve gut microbiota composition, which may help reduce inflammation, a factor linked to T2D.

Conclusion: Substantial evidence links yogurt consumption to better health outcomes

• Numerous high and moderate-quality studies have found an inverse relationship between yogurt intake and type 2 diabetes.
• Yogurt is a nutrient-dense food, providing essential nutrients, and is included in all three healthy dietary patterns recommended by the Dietary Guidelines for Americans.
• Yogurt has a unique food matrix that may contribute to its protective effects on cardiometabolic health, regardless of its fat content.
• These study results are consistent with other research examining the broader health benefits of yogurt consumption.

Thank you for Christopher J. Cifelli, PhD, Senior Vice President of Nutrition Research National Dairy Council, for this intervention on “Exploring the Scientific Evidence: Yogurt and Reduced Risk of Type 2 Diabetes” during the ASN Nutrition 2024 conference “Yogurt and reduced risk of T2D: exploring the new FDA qualified health claim and potential implication for improving public health”.

References

1. Letter of Enforcement Discretion. March 2024.

2. Aune D, Norat T, Romundstad P, et al. Dairy products and the risk of type 2 diabetes: a systematic review and dose response meta-analysis of cohort studies. Am J Clin Nutr. 2013;98:1066–83.

3. Chen M, Sun Q, Giovannucci E, et al. Dairy consumption and risk of type 2 diabetes: 3 cohorts of US adults and an updated meta-analysis. BMC Med. 2014;12:215.

4. Gijsbers L, Ding EL, Malik VS, et al. Consumption of dairy foods and diabetes incidence: a dose-response metaanalysis of observational studies. Am J Clin Nutr. 2016;103:1111–24.

5. Companys J, Pla-Pagà L, Calderón-Pérez L, et al. Fermented dairy products, probiotic supplementation, and cardiometabolic diseases: a systematic review and meta-analysis. Adv Nutr. 2020;11:834–63.

6. Liu S, Choi HK, Ford E, Song Y, Klevak A, Buring JE, Manson JE. A prospective study of dairy intake and the risk of type 2 diabetes in women. Diabetes Care. 2006 Jul;29(7):1579-84.

7. Choi HK, Willett WC, Stampfer MJ, Rimm E, Hu FB. Dairy consumption and risk of type 2 diabetes mellitus in men: a prospective study. Arch Intern Med. 2005 May 9;165(9):997-1003.

8. Guasch-Ferré M, et al. Total and subtypes of dietary fat intake and risk of type 2 diabetes mellitus in the Prevención con Dieta Mediterránea (PREDIMED) study. Am J Clin Nutr. 2017 Mar;105(3):723-735.

9. Díaz-López A, Bulló M, Martínez-González MA, et al. Dairy product consumption and risk of type 2 diabetes in an elderly Spanish Mediterranean population at high cardiovascular risk. Eur J Nutr. 2016;55:349–60.

10. Babio N, B et al; PREDIMED Investigators. Consumption of Yogurt, Low-Fat Milk, and Other Low-Fat Dairy Products Is Associated with Lower Risk of Metabolic Syndrome Incidence in an Elderly Mediterranean Population. J Nutr. 2015 Oct;145(10):2308-16.

11. Drouin-Chartier JP, Li Y, Ardisson Korat AV, et al. Changes in dairy product consumption and risk of type 2 diabetes: results from 3 large prospective cohorts of US men and women. Am J Clin Nutr. 2019;110:1201–12.

12. Drouin-Chartier JP, Hernández-Alonso P, Guasch-Ferré M, et al. Dairy consumption, plasma metabolites, and risk of type 2 diabetes. Am J Clin Nutr. 2021;114:163–74.

13. Trichia E, Luben R, Khaw KT, Wareham NJ, Imamura F, Forouhi NG. The associations of longitudinal changes in consumption of total and types of dairy products and markers of metabolic risk and adiposity: findings from the European Investigation into Cancer and Nutrition (EPIC)-Norfolk study. Am J Clin Nutr. 2020 May 1;111(5):1018-1026.

14. Yuzbashian E, Asghari G, Mirmiran P, Chan CB, Azizi F. Changes in dairy product consumption and subsequent type 2 diabetes among individuals with prediabetes: Tehran Lipid and Glucose Study. Nutr J. 2021 Oct 29;20(1):88.

15. Tremblay A, Panahi S. Yogurt consumption as a signature of a healthy diet and lifestyle. J Nutr. 2017;147:1476S–80S

16. Torres-Gonzalez M, Rice Bradley BH. Whole-Milk Dairy Foods: Biological Mechanisms Underlying Beneficial Effects on Risk Markers for Cardiometabolic Health. Adv Nutr. 2023 Nov;14(6):1523-1537.

17. Weaver CM. Dairy matrix: is the whole greater than the sum of the parts? Nutrition Reviews. 2021;79:4-15.

18. Walther B, Karl JP, Booth SL, et al. Menaquinones, bacteria, and the food supply: the relevance of dairy and fermented food products to vitamin K requirements. Adv Nutr. 2013;4:463–73

Dietary strategies must be devised to target teenagers who are commonly falling short of their nutrient intake requirements, according to research from the Republic of Ireland.

Nutritionists have discovered a concerning trend that many teenagers in Western countries have shortfalls in their diet of micronutrients needed for this critical period of physical and cognitive growth and development (1). Eating dairy foods as part of a balanced and environmentally sustainable diet may help to provide a key source of micronutrients vital for teenage health and wellbeing, the research suggests.

Assessing the nutritional needs of teenagers

As they go through their teenage years, young folk have increasing independence over their food choices and eating behaviour. However, nutrient intakes are not always uppermost in teens’ minds when making their food choices, with potential consequences for health into adulthood (2).

To find out whether teens are getting enough nutrients from their diet, nutrition researchers from Cork, Ireland delved into the micronutrient intakes of teenagers and their implications for public health.

The researchers examined data from recent surveys on micronutrient intakes among teenagers in Europe, Canada, the United States, Australia and New Zealand. They found that Western teenagers are consistently failing to meet recommended intake levels for vitamins A, C, D and E, along with folate, calcium, iron, magnesium, zinc and potassium. This could have far-reaching consequences for bone health, cognitive function, and immunity.

Dairy foods are a key component of bone health in teenagers

Study results showed that intakes of vitamin D, calcium and magnesium are low amongst Western teenagers, with inadequate levels of vitamin D among 70–95%, calcium among 45–73%, and magnesium among 33–88% of teens.

This is important because over half of a person’s bone mass is laid down during the teenage years, requiring sufficient intakes of vitamin D, calcium and magnesium (4). Teenage bone health may be affected by low intakes of these nutrients, resulting in an increased risk of fracture and osteoporosis in later life.

According to the researchers, key sources of calcium, magnesium and vitamin D in teenagers include dairy foods, meat products and fortified cereals. Such nutrient sources should be incorporated into a healthy teenage diet.

A healthy balanced diet can help boost teenage cognitive function

Results also showed that iron and folate intake tend to be low in Western teenagers compared with recommended levels, with inadequate levels of iron and folate in 7–44% and 14–57% of teens, respectively. Iron deficiency is generally more common amongst girls than boys.

This is important because the teenage years are a period of rapid cognitive growth and development, which may be negatively impacted by low intake of folate and iron (3). Iron requirements in particular escalate throughout adolescence due to increased total blood volume and lean body composition, as well as the onset of menstruation in girls.

The researchers highlighted that a combination of dairy, meat, and cereal products provide key sources of iron and folate in teenagers, while vegetables are also an important source of folate.

Teenage diet choices influence general health and immunity

The study found that intakes of nutrients important for general health – including vitamins A, C, E, zinc and potassium – are also generally below recommended levels among Western teenagers.

Low intakes of these vitamins and minerals may result in an increased risk of impaired immunity and susceptibility to infections (5,6).

The researchers pointed out that dairy and meat products are important sources of vitamin A and zinc in teenagers, while fruit and vegetables are key sources of vitamin C. Vegetables, cereals, meat and dairy are all key sources of potassium, while fats and oils are an important source of vitamin E.

So, what can be done to address this issue?

While this study highlights teenage deficiencies in nutrient intake, it also offers some reassurance. Based on current dietary patterns, there seems to be little risk of excessive micronutrient intake, said the researchers.

They concluded that strategies aimed at increasing micronutrient intake among teenagers should focus on boosting intake rather than worrying about overconsumption. Such strategies must be carefully designed and monitored to ensure that they effectively consider the importance of meat and dairy foods to the nutrient intake of teenagers, but are also environmentally sustainable.

“Sufficient micronutrient intakes are crucial during the teenage years to promote optimal health and growth during this life stage and into adulthood, with key dietary habits also forming which have been shown to track into later life.”– Walsh NM, et al., 2024

Source: (1) Walsh NM, Flynn A, Walton J, Kehoe L. Optimal growth and development: are teenagers getting enough micronutrients from their diet? Proc Nutr Soc. 2024 Mar 4:1-9. doi: 10.1017/S002966512400017X.

Additional references

2. Daly AN, O’Sullivan EJ & Kearney JM (2022) Considerations for health and food choice in adolescents. Proc Nutr Soc 81, 75–86.

3. EFSA Panel on Dietetic Products Nutrition and Allergies (2017) Dietary reference values for nutrients summary report. EFSA Support Publ 14, e15121E.

4. Levine MA (2012) Assessing bone health in children and adolescents. na J Endocrinol Metab 16, S205–S212.

5. Carr AC & Maggini S (2017) Vitamin C and immune function. Nutr 9, 1211.

6. Zhao T, Liu S, Zhang R et al. (2022) Global burden of vitamin A deficiency in 204 countries and territories from 1990–2019. Nutrients 14, 950.

YINI attended the 2024 ECO congress to gather scientific updates and expert’s advice on the role of diet and dairy in the management and prevention of obesity. The congress offered a great opportunity to meet with experts from various fields of expertise. Here Odysseas Androutsos, Associate Professor at the Department of Nutrition and Dietetics at the University of Thessaly, speaks about his work on the dietary guidelines for children.

Can you introduce yourself?

I’m an Associate Professor at the Department of Nutrition and Dietetics at the University of Thessaly and Director of the Lab of Clinical Nutrition and Dietetics.

You just gave your presentation at the ECO 2024. What should our readers know about your work?

Based on recent findings, it is evident that childhood obesity has significantly increased over the past decade. The prevalence of obesity in adolescence has quadrupled since the 1990s. According to the latest figures provided by the World Health Organization (WHO), 37 million children under the age of 5 and 390 million children and adolescents worldwide are overweight, with 160 million of them living with obesity.

The severity of this issue requires urgent attention. To address these rising trends, my colleagues and I at the European Specialist Dietetic Network (ESDN) Obesity, under the European Federation of the Associations of Dietitians (EFAD), in collaboration with the European Association for the Study of Obesity (EASO), have developed the latest guidelines for treating obesity in childhood and adolescence.

Could you outline the key principles recommended in these guidelines?

First and foremost, it is essential to recognize obesity as a disease. Therefore, healthcare professionals need to focus on intensive and long-term strategies to optimize treatment for young individuals. Instead of solely concentrating on weight loss or the maintenance of weight loss, we must consider patient-centered health outcomes. This holistic approach aims to achieve results that impact overall health and disease management.

Furthermore, through the implementation of these long-term and regular interventions, we emphasize medical nutrition therapy to maintain an energy deficit and sustain the weight loss achieved. Concurrently, our optimized approach ensures the provision of essential nutrients to develop healthy diet plans. These plans will not only lead to initial weight loss but also help in maintaining a healthy weight over time.

What are the key considerations and strategies for developing effective obesity treatment plans for children and adolescents?

While focusing on weight management, it is equally important to ensure that children and adolescents receive optimal nutritional intake to meet their requirements. This is crucial from our perspective. We must promote and incorporate low-energy, nutrient-dense foods, such as yogurt, fruits and vegetables, into their diet plans. Replacing energy-dense foods like salty snacks and sweets with healthier options is essential, not only during main meals but also in intermediate meals and breakfast.

Evidence from literature and our recommendations shows, for example, that increasing fruit intake by 0.5 servings and vegetable intake by 1.5 servings per day can be sustained over a long period. Our treatment approach must be personalized, as a one-size-fits-all strategy is ineffective. Specific, measurable, and time-related goals should be set for each patient to meet their unique needs and expectations.

Working in multidisciplinary teams is vital. Collaboration among pediatricians, dietitians, nutritionists, physical education experts, psychologists, and other professionals ensures optimal results. This team approach addresses psychological, social, and physical health aspects of obesity.

Role modeling is another crucial aspect. It extends beyond healthcare professionals to include families, parents, caregivers, teachers, and others in the child’s social environment. Promoting healthy role models is essential. Additionally, using non-stigmatizing, person-first language is important. We must respect and work individually with each person to optimize our efforts.

The care environment must be safe and welcoming, making children and adolescents feel comfortable and happy. These are the main pillars of creating a healthy environment for providing care. Overall, these are the core goals of the medical nutrition therapy described in our recommendations.

What is the place of dairy products in the guidelines, and more specifically yogurt?

Dairy products are an integral part of a healthy dietary pattern and should certainly be included when prescribing healthy diets for children. Their inclusion is not solely for the treatment of overweight or obesity; rather, dairy should be a regular component of the diet plan for all children and adolescents.

In the context of obesity treatment, dairy products provide essential nutrients crucial for growth in children and adolescents, such as proteins and calcium. Additionally, yogurt offers beneficial ferments that positively affect gut microbiota, which play a significant role in maintaining a healthy diet. Incorporating these microbial benefits is an important aspect of effective obesity treatment.

Do you have a message for dietitians on how they can effectively utilize these guidelines?

Dietitians looking to utilize these guidelines can easily access them. The guidelines are uploaded and freely available on the websites of EASO and EFAD. Anyone interested can simply click on the links to access the information. Our committee is also open to any questions and future networking opportunities to optimize the implementation of these recommendations.

Additionally, it is important to note that we are actively working with healthcare professionals to gather their feedback. Through qualitative research methods, such as interviews and focus groups, we are collecting their views and suggestions on how to enhance the implementation of these guidelines. While we have compiled the best available evidence, another crucial step is optimizing the guidelines’ uptake and integration into health systems across Europe, ensuring they are effectively implemented in daily practice.

References:

• European Association for the Study of Obesity Position Statement on Medical Nutrition Therapy for the Management of Overweight and Obesity in Adults Developed in Collaboration with the European Federation of the Associations of Dietitians
• EASO and EFAD Position Statement on Medical Nutrition Therapy for the Management of Overweight and Obesity in Children and Adolescents

YINI attended the 2024 ECO congress to gather scientific updates and expert’s advice on the role of diet and dairy in the management and prevention of obesity. The congress offered a great opportunity to meet with experts from various fields of expertise. Here Maria Hassapidou, Professor of Nutrition and Dietetics at the Alexander Technological Educational Institution of Thessaloniki (Greece) tells us about her work on the dietary guidelines for Obesity in Europe.

Can you introduce yourself?

I am a Professor of Nutrition and Dietetics at the International Hellenic University in Thessaloniki, Greece, and I chair the ESDN Obesity of EFAD, the specialized dietetic group on obesity of the European Federation of the Association of Dietitians. Additionally, I co-chair the Nutrition Working Group of the European Association for the Study of Obesity (EASO).

For the past decade, our collaboration between dietitians and obesity experts has been immensely beneficial. This synergy between the two groups was instrumental in the joint publication of the guidelines.

During the Congress, we observed that a multidisciplinary approach is crucial for managing obesity. Can you share the method used to develop the dietary guidelines?

As I mentioned during my presentation, our journey began with an EU umbrella project, providing an opportunity to develop dietary guidelines for obesity, particularly focusing on medical nutrition therapy. We conducted surveys across Europe to assess the existing guidelines and published comparative studies to identify similarities and differences. This process highlighted the need for unified European guidelines, which was strongly supported by scientists and healthcare professionals across various countries.

To address this, we collaborated between EFAD and EASO, forming working and writing groups. We conducted a systematic literature review, drawing heavily on the comprehensive Canadian guidelines for obesity treatment. By extending their methodology up to 2023 and sharing our findings with our Canadian colleagues, we benefited greatly from this collaboration. Simultaneously, we developed guidelines for children with obesity, incorporating significant contributions from Australian researchers and maintaining the same rigorous methodology.

Our guidelines categorize the strength of evidence into various grades and levels based on the methods used. I hope, as I mentioned, that we have produced a well-received consensus document. Initial feedback from dietitians and the European Federation Association has been positive, but it will take time to evaluate the practical implementation and effectiveness of these guidelines.

What are according to you the main highlights from these dietary guidelines?

As I mentioned during my presentation, the key point of these guidelines for both adults and children is the emphasis on treating comorbidities. These guidelines are not solely focused on weight loss or reducing BMI: their primary goal is to improve overall health. Medical nutrition therapy aims to reduce comorbidities, making health improvement the main objective. Different diets are graded based on evidence, demonstrating their effectiveness in reducing factors like cholesterol or blood pressure. While losing weight is important, maintaining overall health is paramount.

Another important aspect is the grading of different diets. We have gathered extensive information, including evidence on specific food groups. Common questions often revolve around the effects of particular foods, such as nuts or vegetables. For example, there is strong evidence that increasing vegetable intake can help reduce body weight. A significant focus of the guidelines is dedicated to food groups, with particular interest in dairy products.

Regarding dairy, we have a specific recommendation based on evidence. There was a substantial number of studies showing positive results for certain health parameters related to dairy consumption. Overall, the inclusion of dairy, and specifically yogurt, is supported by evidence in our guidelines.

In March 2024, the FDA accepted a qualified health claim on the preventive role of yogurt in type 2 diabetes. Is it something that could lead to an update of dietary guidelines?

There are European guidelines for diabetes that are updated every few years, managed by specialists in that field. Our focus is on obesity, so I can’t provide specific data on diabetes. However, as a nutritionist, I can say that yogurt plays a significant role in the microbiota, which is related to both obesity and diabetes. The type of yogurt matters, and there is substantial evidence supporting its benefits through physiological mechanisms.

Where or how can dietitians find the guidelines?

Dietitians can access our guidelines by downloading the free papers available online. They are also accessible on the EASO and EFAD websites. To encourage their use, we are planning workshops and webinars for health professionals to ensure they are aware of these guidelines. These efforts are being made through EASO, EFAD, and national associations. While it will take some time for the guidelines to be fully integrated, initial feedback from health professionals, especially dietitians, has been very positive, and they have expressed their intention to use them.

References:

• European Association for the Study of Obesity Position Statement on Medical Nutrition Therapy for the Management of Overweight and Obesity in Adults Developed in Collaboration with the European Federation of the Associations of Dietitians
• EASO and EFAD Position Statement on Medical Nutrition Therapy for the Management of Overweight and Obesity in Children and Adolescents

YINI attended the 2024 ECO congress to gather scientific updates and expert’s advice on the role of diet and dairy in the management and prevention of obesity. The congress offered a great opportunity to meet with experts from various fields of expertise.

Here Dr Michele Sculati, Medical Doctor, Clinical Nutrition Specialist, PhD Public Health in Italy, speaks about the significance of addressing obesity with a comprehensive approach that includes newly available drugs, lifestyle changes, dietary adjustments, and the beneficial roles of prebiotics, probiotics, and fermented foods on the gut microbiota.

Can you introduce yourself?

I am a medical doctor specializing in Clinical Nutrition, with a strong focus on diet and dietotherapy, areas typically managed by dietitians. My passion lies in understanding how food and dietary habits can influence our health. Additionally, I have a deep interest in endocrinology and metabolism. This Congress, the ECO 2024, covers many of these topics extensively, making it an exciting and relevant event for me.

What do you believe are the key learnings from the ECO 2024 Congress?

There are numerous key messages to consider, given that the scientific program is an extensive 300-page document! Obesity has garnered significant interest, particularly with the advent of new treatment results. One of the most discussed topics is the efficacy of new drugs, including not only GLP-1 inhibitors but also others GP inhibitors and emerging medications. Currently, we have around 20 new molecules in development, making it possible to treat obesity with drugs, in addition to surgery.

However, prescribing drugs alone is not sufficient. When treating a patient with obesity, it’s crucial to remember that better results are achieved if the patient’s habits are changed. Therefore, a nutritionist or medical doctor treating obesity should emphasize the importance of personalized dietary prescriptions. These prescriptions should be tailored to the patient’s needs and habits, ensuring they are practical and achievable in real life. This includes considering the patient’s taste preferences, food preparation time, daily schedule, and activities such as sports or the use of lunch boxes.

Beyond the combination of drug development, clinical approaches and personalized dietary prescriptions, are there new targets in obesity research?

An area of growing interest among scientists is how dietary habits affect the microbiota, which plays a significant role in weight regulation. The microbiota aids in regulating weight through GLP-1. A diet rich in fiber and a healthy microbiota can lead to the production of short-chain fatty acids. These acids stimulate G protein on enterocytes, which in turn promotes the secretion of glucagon-like peptide-1 (GLP-1), the same target as many GLP analog drugs.

In recent years, there has been a shift towards prescribing diets that positively impact the microbiota by enhancing the fermentation of short-chain fatty acids. This can be achieved through diet, prebiotics, and probiotics. Probiotics are not limited to pills or supplements but can also be found in foods like yogurt, which naturally contain probiotics.

Many foods have potential probiotics. However, the way we cook, prepare, and store these foods affects their probiotic content. In contrast, yogurt is a standardized food with known probiotic content and substantial scientific backing.

Based on the sessions you attended here at ECO 2024, can you think of new benefits yogurt may bring to the microbiota?

Definitely! For example, I attended sessions on Metabolically Associated Steatohepatitis (MASH), previously known as Non-Alcoholic Steatohepatitis (NASH). These sessions highlighted the connection between the microbiota and the liver. Poorly differentiated microbiota, lacking healthy taxa, can lead to a thinner mucus layer in the gut, causing a condition known as leaky gut. This allows chemicals like lipopolysaccharides to pass through enterocytes into the bloodstream, reaching the liver directly.

Lipopolysaccharides impact inflammation mediators in the liver, contributing to chronic inflammation associated with non-alcoholic fatty liver disease (NAFLD) and MASH. Once again, as previously stated, modulating the microbiota through dietary habits and probiotics can play a crucial role in managing these conditions.

In March, the FDA accepted a claim that yogurt can help prevent type 2 diabetes. How significant is this claim for clinicians, and will it impact their recommendation of yogurt?

This claim is the result of decades of research, marking a significant milestone. I don’t believe any other food has such a strong claim related to a globally prevalent health issue like type 2 diabetes, making this incredibly important.

It’s not just based on a few years of research; it’s the culmination of extensive studies. While the FDA doesn’t consider the evidence entirely conclusive, the claim they approved is still very strong. We know there’s a negative association between yogurt consumption and the incidence of diabetes: the more yogurt you consume, the lower your risk of developing diabetes.

The exact reasons for this observation are still under investigation. It could be due to bioactive peptides in yogurt or its influence on the microbiota. As mentioned earlier, diet can affect the endogenous secretion of GLP-1, which was initially developed as a drug for diabetes therapy. This might give us some insight into why these observations occur.

Besides diabetes, yogurt offers numerous benefits: it is a nutrient-dense food, which likely explains the negative association between yogurt consumption and BMI. Additionally, yogurt consumption is associated with overall healthy dietary habits.

What is vitamin D?

Vitamin D is a fat-soluble vitamin. It exists on 2 different forms, D2 (ergocalciferol), mainly produced by some plants and D3 (cholecalciferol). The human body synthesizes vitamin D3 in the skin, under the effect of ultraviolet rays.

Vitamin D is known for its significant role in calcium homeostasis and metabolism but it plays a multitude of effects on the body besides bones and calcium metabolism by contributing to:

• the normal function of the immune system
• inflammatory response
• muscle functions

The roles of vitamin D

Vitamin D promotes healthy bones by aiding calcium absorption through modulation of active transport absorption and maintaining a good ratio of calcium and phosphate for bone mineralisation.

It reduces inflammation, modulates cell growth, glucose metabolism, neuromuscular and immune function through the modulation of genes encoding proteins that regulate these processes.

A chronic deficiency in vitamin D leads to improper bone mineralisation, as less calcium and phosphorous are absorbed in the small intestine and can induce hypocalcaemia (low levels of calcium in the blood) and phosphaturia (phosphate in urine) causing accelerated bone demineralization. This can result in bone mineralisation diseases such as osteomalacia, osteoporosis, and rickets in children. Adequate levels of vitamin D combined with calcium can help prevent these diseases.

Vitamin D consumed in the diet is absorbed through passive diffusion in the gut and this absorption is enhanced by fat.

Diet recommendations

Vitamin D is synthesised by the skin when exposed to UV light. However, the amount synthesised depends on a multitude of factors such as where you live, weather, skin melanin levels, and wearing sunscreen.

Diet recommendations usually assume skin endogenous production of vitamin D is equal to 0 to ensure guidelines provide enough vitamin D through diet alone. The recommended daily intake is 15µg per day for adults. The ability of the body to produce and absorb vitamin D decreases with age which is why this recommendation increases to 20µg per day for people over the age of 70.

It is important not to consume too much vitamin D because excess vitamin D in the body is toxic and can lead to symptoms such as headache, nausea and vomiting, weight loss or fatigue. It is recommended to not consume more than 100µg per day. However, this happens almost only in cases of supplement overuse and it is not something the majority of the population has to worry about. In fact, most people fall short of meeting recommended intakes. In the USA, over 90% of adults do not consume enough vitamin D and this is similar in most northern hemisphere countries.

Dietary sources of vitamin D

Dietary sources of vitamin D are quite rare. Some vitamin D can be found in fatty fish, fish liver oils, beef liver, egg yolk, cheese and fortified dairy. For example, in the USA, almost all milk is fortified with vitamin D and it is compulsory in Canada.

Some mushrooms can have vitamin D if they are treated with UV light which makes the mushroom produce vitamin D.

Vitamin D in dairy

As dairy products are often fortified in vitamin D, it is a major source of this nutrient for populations. For example, in France, 25% of vitamin D intake comes from dairy products.

Dairy products were chosen to be fortified as it doesn’t change the taste and it also helps in absorbing the high content of calcium and ensure healthy bones.

Fortified dairy products are an interesting source of vitamin D as they provide a large portion of the dietary recommendation.

Data from the USA National Health Nutrition and Examination Survey (NHANES), the Canadian Community Health Survey, and the UK National Diet and Nutrition Survey show that yogurt consumers have higher daily intakes of several key nutrients including vitamin D.

Research shows that people that consume yogurt have stronger bones and lower bone resorption markers. In older adults, yogurt consumption is linked to increased bone mineral density and physical function. Therefore, encouraging older people to eat yogurt more often, particularly vitamin D- and calcium-fortified yogurt, may be a valuable public health strategy to stave off osteoporosis.

See also

• Boost your vitamin D with fortified yogurt
• Eat your way to stronger bones: fermented dairy may help

Sources

• Office of Dietary Supplements – Vitamin D.

• Sizar O, Khare S, Goyal A, Givler A. Vitamin D Deficiency. StatPearls. Treasure Island (FL): StatPearls Publishing; 2024.

• Vitamin D: why do I need an adequate intake and how can I make sure I get it ? In: Anses – Agence nationale de sécurité sanitaire de l’alimentation, de l’environnement et du travail [Internet]. 2 Mar 2022 [cited 13 Feb 2024].

• EUFIC – Vitamin D: foods, functions, how much do you need & more.

• CIQUAL – La table de composition nutritionnelle des aliments. ANSES, France.

• Zhu Y, Jain N, Holschuh N, et al. Associations between frequency of yogurt consumption and nutrient intake and diet quality in the United Kingdom. J Nutr Sci. 2021;10:e85.

• US Department of Agriculture and US Department of Health and Human Services. Dietary Guidelines for Americans, 2020–2025. 9th Edition. December 2020.

• Cifelli CJ, Agarwal S, Fulgoni VL. Association of yogurt consumption with nutrient intakes, nutrient adequacy, and diet quality in American children and adults. Nutrients. 2020;12:3435.

• Vatanparast H, Islam N, Prakash Patil R, et al. Consumption of yogurt in Canada and its contribution to nutrient intake and diet quality among Canadians. Nutrients. 2019;11:1203.

• He M, Yang YX, Han H, et al. Effects of yogurt supplementation on the growth of preschool children in Beijing suburbs. Biomed Environ Sci. 2005;18:192–7

• Laird E, Molloy AM, McNulty H, et al. Greater yogurt consumption is associated with increased bone mineral density and physical function in older adults. Osteoporos Int. 2017;28:2409–19.

• Bonjour JP, Benoit V, Payen F, et al. Consumption of yogurts fortified in vitamin D and calcium reduces serum parathyroid hormone and markers of bone resorption: a double-blind randomized controlled trial in institutionalized elderly women. J Clin Endocrinol Metab. 2013;98:2915–21.

• Bonjour JP, Benoit V, Atkin S, et al. Fortification of yogurts with vitamin D and calcium enhances the inhibition of serum parathyroid hormone and bone resorption markers: a double blind randomized controlled trial in women over 60 living in a community dwelling home. J Nutr Health Aging. 2015;19:563–9.

• Sahni S, Mangano KM, Kiel DP, et al. Dairy intake is protective against bone loss in older vitamin D supplement users: the Framingham study. J Nutr. 2017;147:645–52.

YINI attended the 2024 ECO congress to gather scientific updates and expert’s advice on the role of diet and dairy in the management and prevention of obesity. The congress offered a great opportunity to meet with experts from various fields of expertise. Here Niam Arthurs, pediatric dietitian and researcher in the area of child and adolescent obesity based in Dublin, Ireland, speaks about her research on child obesity.

Can you introduce yourself and tell us what you work on?

I’m a senior pediatric dietitian and researcher in the area of child and adolescent obesity based in Dublin, Ireland. My team works on food habits among children with obesity. Our main objective is to gather intelligence about our young patients’ habits before implementing any obesity treatment in order to maximize the effectiveness of personalized dietary approaches.

Firstly, we examine the nutritional quality of children’s reported food and fluid intakes. For this specific aspect, we use a 28-item food frequency questionnaire, conducted with the parents.

Secondly we evaluate the level of parental knowledge about nutrition, their self-reported cooking confidence and their relationship to food consumption. Ultimately, these elements guide us in determining the relationship between parental nutritional knowledge and children’s dietary habits. That is the basis for tailoring personalized treatment.

What have you learned about personalized dietary treatment for children with obesity using this method?

Getting a baseline idea about what children and teenagers are actually eating, combined with parents’ nutrition knowledge and their ease with cooking preparations allowed us to avoid making assumptions about children’s environments. This truly helped us make the connection between gathered information and its relationship with food consumption.

Our study found that parents who reported lower levels of cooking confidence tended to have households with higher consumption of convenience meals and takeaway foods. For dietitians aiming at framing their patients’ specific needs, such elements represent key targets for designing their interventions.

Assessing levels of knowledge in nutrition also enables understanding of general food and nutrient recommendations knowledge. We observed that the consumption of dairy products was a lot lower than the recommended amounts, in all age groups. From 5- to 88-year-olds, only about over 50% of the studied population met the recommended daily intakes for dairy products.

In Ireland, dairy products are the main source of calcium in children’s and teenagers’ diets. This nutrient is of pivotal importance during this age of growth. However, none of the 9- to 16-year-olds included in the survey met the recommended daily intakes for calcium, from either dairy products or other calcium-rich foods.

Again, the study aims at identifying such key target points to let dietitians design relevant interventions.

How do these results translate in your day-to-day consultation?

Expanding on the earlier example of calcium deficiency, the study highlighted that our interventions need to focus more on dairy products. This implies addressing the myths around dairy products and exploring with the families the reasons why they do not consume enough dairy products, particularly children and teenagers.

In this instance, it appears that a lot of the parents simply do not know what the recommendations for dairy foods are – i.e. 3 portions of dairy foods per day from up to 8 years, and 5/day after 8 years old, in Ireland – nor what a serving size corresponds to.

That information is crucial for health and nutrition literacy, and we need to incorporate it more into our one-on-one consultations and group education programs to ensure that individuals are receiving adequate levels of necessary knowledge.

Do you provide them with simple ways to incorporate more dairy into their meals?

This is where tailoring comes in. It’s important to understand what children and teenagers are currently eating to make small, specific suggestions for incorporating more dairy. For example, many children begin skipping breakfast when they transition from primary to secondary school, often due to time constraints or lack of appetite. However, breakfast is an important opportunity to consume calcium-rich foods.

We can suggest alternatives such as eating something once they get to school or choosing quicker options for the morning to overcome time barriers. Additionally, they can incorporate more calcium-rich foods into their lunch. For instance, they could add cheese to their sandwiches or bring pouch yogurts, which are convenient and less likely to burst in their bags. Drinkable yogurts are also a good option. These types of recommendations are often more acceptable and practical for their routines.

In March 2024, the FDA published a qualified health claim about the role of yogurt in the prevention of type 2 diabetes. Can this have an impact on the recommendations? Do you think it can be an opportunity for patients?

It’s incredibly valuable to have strong, evidence-based claims because there’s so much misinformation surrounding dairy foods. For instance, myths about dairy contributing to acne, containing hormones, or causing inflammation are not supported by scientific evidence. Unfortunately, the science community isn’t reaching these target groups effectively. Families are increasingly getting their information from social media, so we need to be much louder in our communication. Having well-supported claims can help us do that.

Moreover, these claims are particularly significant in our world today, where we face rising rates and high prevalence of conditions like type 2 diabetes. These conditions can severely impact an individual’s quality of life and health if not properly managed. Strong, scientifically-backed claims not only help us communicate more effectively but also attract media attention. This can encourage individuals, families, and teenagers who might be avoiding calcium-rich foods, such as dairy products, to reconsider their choices.