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Revised draft Clinical Practice Guidelines for the Management of Overweight and Obesity in Adults, Children and Adolescents

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42
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Organisation Name: 
Dairy Australia
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No
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6.1 Lifestyle interventions

PART B Weight Management in Adults On page 20 of the draft Guidelines,

Section 6.1 Lifestyle interventions

6.1.1 Reducing energy intake

 For weight loss, it is important to ensure that dietary interventions are designed to create an energy deficit, suit the needs and preferences of individuals and include a wide variety of nutritious foods as recommended by the draft Australian Dietary Guidelines

Guideline 1.  Eat a wide variety of nutritious foods from these five groups every day:

  • plenty of vegetables, including different types and colours, and legumes/beans
  • fruit
  • grain (cereal) foods, mostly wholegrain, such as breads, cereals, rice, pasta, noodles, polenta, cousous, oats, quinoa and barley
  • lean meat and poultry, fish, eggs, nuts and seeds, and legumes/beans
  • Milk, yogurt, cheese and /or their alternatives, mostly reduced fat (reduced fat milks are not suitable for children under the age of 2 years).

And drink water.

 

Table 6.1 – includes reference to draft Australian Dietary Guideline recommendations for healthy eating

 

 

 

 

 

 

 

 

 

 

 

Dairy Australia would like to bring to the attention of the OGDC some key points from our submission provided to the NHMRC in February 2012 on the draft Australian Dietary Guidelines which address key concerns relating to the dairy foods guideline (highlighted above).

To provide some context to our comments, Dairy Australia would like to highlight the widespread under consumption of core dairy foods in Australia and the significance of the health benefits associated with an adequate level of consumption of core dairy foods.

An estimated 58% of male and 73% of female Australians aged 12 years and older consume less than the minimum recommended intake of core dairy foods outlined in the 1998 Australian Guide to Healthy Eating (Doidge & Segal 2012) and are therefore, likely to be missing out on dairy foods’ key health benefits. 

These health benefits have been reviewed recently by the Dietary Guidelines Working Committee and are summarized in the evidence statements on pages 62-64 in the draft Australian Dietary Guidelines (NHMRC, 2011). The evidence statements indicate that consumption of higher amounts of milk/dairy foods is associated with a reduced risk of ischemic heart disease, myocardial infarction, stroke, hypertension, type 2 diabetes, metabolic syndrome and colorectal cancer – the main causes of death in Australia.  It is also associated with improved bone mineral density and there is no association between consumption of dairy foods and weight change/obesity.  Importantly, all of the health benefits associated with the consumption of milk/dairy foods detailed in the evidence statements relate equally to reduced-fat and regular fat products.

Key points from Dairy Australia’s submission on the draft Australian Dietary Guidelines (NHMRC, 2011)

 

  • There is no evidence in the food specific evidence statements supporting the view that reduced-fat milk, cheese or yoghurt are healthier than regular fat ones.
  • All of the health benefits associated with the consumption of milk, yogurt and cheese outlined in the evidence statements relate equally to reduced-fat and regular fat products.
  • Dairy Australia commissioned CSIRO to undertake dietary modelling using similar methods to the Food Modelling document.  This new CSIRO dietary modelling (Riley, 2012) demonstrates that a food intake pattern CAN be selected where core dairy food intake is entirely or predominantly from the medium fat and high fat dairy food categories which is nutritionally equivalent or superior to the draft AGHE recommendations for energy and the 10 key ‘driver’ nutrients.  
  • Dairy Australia presented an evaluation of the evidence against the five key evidence streams which the NHMRC drew upon in developing the Guidelines, which demonstrates that the ‘mostly reduced-fat’ advice for milk, yogurt and cheese should be omitted
    • The ‘mostly reduced-fat’ advice may fit with the modelling but is not consistent with the Evidence Report.
    • Omitting the ‘mostly reduced-fat’ phrase from the Guideline wording makes the guideline more scientifically accurate because it more accurately reflects the dairy foods evidence statements while (as the CSIRO modelling (Riley 2012) demonstrates) also fitting in with the Modelling parameters.
    • A key authoritative report, the 2010 FAO/WHO Expert Consultation on Fats and Fatty Acids in Human Nutrition, did not specify ‘mostly reduced-fat’ for core dairy foods in its food-based dietary guidelines recommendations.   
    • On the basis of the points discussed above, Dairy Australia recommends that the draft Australian Dietary Guideline on dairy foods be revised to read as follows:

      Milk, yogurt, cheese and/or alternatives (reduced-fat milks are not suitable for children under 2 years).

       

      This amendment represents an incremental development from the 2003 Dietary Guidelines, reflecting a body of recent scientific knowledge, i.e. it is not a revolutionary change from the previous Guidelines.

 

 

Further details presented in Dairy Australia’s submission to the NHMRC on the draft Dietary Guidelines are provided in Appendix 1.

Moreover, of particular relevance to this consultation there is NO evidence that consuming reduced-fat core dairy foods leads to a lower risk of weight gain, overweight or obesity.

  • In a 2011 systematic review of prospective cohort studies to assess the longitudinal relationship between habitual dairy consumption and the risk of overweight/obesity consumption of dairy foods showed no harmful effect on weight status, in either children or adults (Louie et al., 2011).  Moreover, contrary to popular belief, low-fat dairy products were not found to be more beneficial to weight status than regular fat dairy products.  In fact, the reverse may be true.  The paper concludes ‘In summary, there is currently insufficient evidence to conclude that increased dairy consumption, particularly of regular fat varieties, is associated with weight status.
  • No relationship was found between consumption of either whole milk, or low fat/skim milk or cheese and weight gain in a 2011 pooled analysis of data from three prospective cohort studies in which the dietary intake of 120,877 US men and women was followed for 12 years or 20 years (Mozaffarian et al., 2011). (In contrast, of all the foods, yogurt consumption was associated with the greatest decline in body weight – four times as much weight loss as a serving of vegetables and one-and-a-half times as much weight loss as a serve of fruit).
  • Hendrie and Golley (2011) observed that changing from regular fat dairy foods to reduced-fat varieties had no effect on total energy intake or adiposity measures (BMI, BMI z-score or waist circumference) in a 24 week randomised controlled trial in Australian children. 

 

13.2 Supporting weight management

Under PART C – CHILDREN AND ADOLESCENTS 13.2 Supporting Weight Management. Case studies – supporting weight management in children

Case Study 12*

“…..and dietary habits put her at risk of weight gain (skipping breakfast, snacking and consuming full-cream milk and soft drink)……..”

There is NO evidence to support that consuming full-cream or regular fat milk is a dietary habit that increases risk of weight gain. To describe consumption of regular milk in this context is inappropriate. Milk is a nutrient rich core food that makes a valuable contribution to the diet. As described on the previous page, the dietary modeling conducted for the draft Australian Dietary Guidelines included regular fat milk.   

A recent Australian study (Hendrie & Golley, 2011) is the first randomised controlled study to assess the effects of changing from regular-fat to reduced-fat dairy foods (as the only intervention) on dietary intake. 

Methods

A 24 week cluster randomised controlled trial was conducted in children (4 to 13 years) to test the effects of changing from regular-fat dairy foods to reduced-fat varieties on dietary intake, metabolic and anthropometric outcomes.  The parents of the intervention group received individualised nutrition education from a research dietitian about the importance of dairy foods for children and the need to change their children from regular to low fat dairy foods.  The parents in the control group received individual advice by a research dietitian about reducing children’s screen time and replacing it with other sedentary activities.  These parents were given no specific dietary or dairy specific education and were encouraged to continue with their usual dietary pattern.  Parents were given their advice by the research dietitian during 30 minute appointments during weeks 1, 5 and 9.   Measurements were taken at baseline, at the end of the 12 week intervention, and 12 weeks later. 

Results

145 children from 93 families participated in the study and the children in the intervention successfully changed their dairy intake – regular fat dairy foods decreased from 88% to 18% of dairy intake in the intervention group at 24 weeks.  As would be expected, this led to a significant decrease in saturated fat intake by the intervention group – intake was 3.3 percentage points lower in the intervention group at week 24 compared with the control group.  However, carbohydrate intake (% energy) increased in the intervention group – intake was 4.1 percentage points higher in the intervention group at week 24 compared with the control group.  (Absolute amounts of carbohydrate were not significantly different). 

Importantly, changing from regular fat to reduced fat dairy foods had no effect on total energy intake or adiposity measures (BMI, BMI z-score or waist circumference). 

Moreover, the fact that saturated fat was replaced by carbohydrates may have even increased risk of CHD, particularly if the carbohydrates were refined.  The 2011 FAO/WHO expert consultation on ‘Fats and fatty acids in human health’ concluded that ‘there is probable evidence that replacing SFA with largely refined carbohydrates has no benefit on CHD and may even increase the risk of CHD and favour metabolic syndrome development.’   

The observation that switching from regular-fat dairy foods to low-fat types did not lead to an overall decline in energy intake is very important.  Clearly, the children compensated for the reduced energy within their dairy foods by consuming other foods.  This suggests that the basis for recommending people simply switch from regular-fat dairy foods to reduced-fat varieties in order to help reduce obesity is flawed. It also supports the results from prospective cohort studies suggesting there is no advantage of reduced-fat dairy foods over regular-fat versions for weight gain – both are unrelated to weight gain. 


General comments
Comments: 

 

 

 

 

 

Response to the NHMRC on:

Management of Overweight and Obesity in Adults, Adolescents and Children.

Draft Clinical Practice Guidelines for Primary Care Health Professionals

 

 

 

 

 

Prepared by Dairy Australia

on behalf of the Australian Dairy Industry


The Australian Dairy Industry

Dairy Australia welcomes the opportunity to present this submission in response to Management of Overweight and Obesity in Adults, Adolescents and Children, draft Clinical Practice Guidelines for Primary Health Professionals.

Dairy Australia is the dairy industry-owned service company, limited by guarantee, whose members are farmers and industry bodies, including the Australian Dairy Farmers, and the Australian Dairy Products Federation.

The dairy industry is one of Australia’s major rural industries.  Based on farm gate value of production, it is ranked third behind the beef and wheat industries.  There are approximately 7,500 farmers producing more than 9 billion litres of milk annually.

 

 

 

 

Executive Summary

Dairy Australia commends the NHMRC on their review of Clinical Practice Guidelines for the Management of Overweight and Obesity in Children, Adolescents and Adults and the development of recommendations based on the most recent evidence. Dairy Australia acknowledges the concerning prevalence of overweight and obesity in Australia and commends the systematic approach taken by the NHMRC in the development of these clinical Practice guidelines for primary health care professionals. We also note in the draft Guidelines the broader scope of the Guidelines beyond weight (Introduction section on page xii under ‘Dissemination, implementation and review’) with reference to:

“Where possible and or/appropriate, the dissemination and availability of the Guidelines will be linked to the Healthy Weight Guide and /or with other associated DoHA guidelines currently being produced relating to clinical chronic disease management and associated risk factors within primary care.”

Given these guidelines will also underlie advice by DoHA for other documents targeted to primary care, community care and the Australian public, Dairy Australia would like to provide comment as follows:

(1)  

  • The body of evidence as summarized in the evidence statements presented in the draft Australian Dietary Guidelines (NHMRC, 2011) show the strengthening of the evidence base for the health benefits of core dairy foods in relation to reduced risk of chronic disease.
  • Dairy Australia believes the draft Australian Dietary Guideline recommendation to consume ‘mostly reduced-fat’ milk, yogurt and cheese is likely to have a negative impact on overall consumption of dairy foods, reducing people’s chances of meeting dairy recommendations and accessing the health benefits associated with adequate consumption.
  • The draft Australian Dietary Guidelines find NO association between consumption of dairy foods and weight change/obesity. All of the health benefits associated with the consumption of milk/dairy foods detailed in the evidence statements relate equally to reduced-fat and regular fat products.
  • There is NO evidence to support that consuming full-cream milk is a dietary habit that increases risk of weight gain. 

Comment on a number of specific references to dairy foods in the draft Guidelines.

 

 

 

 

 

 

 

 

 

 

 

 

(2)  

Recently published papers outline some important developments in our under- standing of the effects of dairy foods on body weight, overweight and obesity.  Together they suggest that:

  • Dairy foods may help with appetite control.
  • Regular-fat dairy foods have a neutral effect on weight, they are not foods to cut out.
  • Swapping from regular-fat to reduced-fat dairy products may not lead to reduced overall energy intake.
  • For core dairy foods, it is best to focus on quantity rather than type i.e. ensuring an adequate dairy intake (3 serves) rather switching from regular to reduced fat varieties.
  • For weight loss, dairy foods are superior to other sources of calcium (e.g. supplements and soy drink).
  • Yogurt should be top of mind for inclusion in weight loss diets.  In the long term, eating yogurt has been found to be associated with greater weight loss than foods such as fruit, vegetables and whole grains.

 

 

Additionally bring to the attention of the Obesity Guidelines Development Committee (OGDC) some significant recent evidence in relation to dairy foods, energy intake and body weight.

 


COMMENT ON A NUMBER OF SPECIFIC REFERENCES TO DAIRY FOODS IN THE DRAFT GUIDELINES

PART B Weight Management in Adults On page 20 of the draft Guidelines,

Section 6.1 Lifestyle interventions

6.1.1 Reducing energy intake

 For weight loss, it is important to ensure that dietary interventions are designed to create an energy deficit, suit the needs and preferences of individuals and include a wide variety of nutritious foods as recommended by the draft Australian Dietary Guidelines

Guideline 1.  Eat a wide variety of nutritious foods from these five groups every day:

  • plenty of vegetables, including different types and colours, and legumes/beans
  • fruit
  • grain (cereal) foods, mostly wholegrain, such as breads, cereals, rice, pasta, noodles, polenta, cousous, oats, quinoa and barley
  • lean meat and poultry, fish, eggs, nuts and seeds, and legumes/beans
  • Milk, yogurt, cheese and /or their alternatives, mostly reduced fat (reduced fat milks are not suitable for children under the age of 2 years).

And drink water.

 

Table 6.1 – includes reference to draft Australian Dietary Guideline recommendations for healthy eating

 

 

 

 

 

 

 

 

 

 

 

Dairy Australia would like to bring to the attention of the OGDC some key points from our submission provided to the NHMRC in February 2012 on the draft Australian Dietary Guidelines which address key concerns relating to the dairy foods guideline (highlighted above).

To provide some context to our comments, Dairy Australia would like to highlight the widespread under consumption of core dairy foods in Australia and the significance of the health benefits associated with an adequate level of consumption of core dairy foods.

An estimated 58% of male and 73% of female Australians aged 12 years and older consume less than the minimum recommended intake of core dairy foods outlined in the 1998 Australian Guide to Healthy Eating (Doidge & Segal 2012) and are therefore, likely to be missing out on dairy foods’ key health benefits. 

These health benefits have been reviewed recently by the Dietary Guidelines Working Committee and are summarized in the evidence statements on pages 62-64 in the draft Australian Dietary Guidelines (NHMRC, 2011). The evidence statements indicate that consumption of higher amounts of milk/dairy foods is associated with a reduced risk of ischemic heart disease, myocardial infarction, stroke, hypertension, type 2 diabetes, metabolic syndrome and colorectal cancer – the main causes of death in Australia.  It is also associated with improved bone mineral density and there is no association between consumption of dairy foods and weight change/obesity.  Importantly, all of the health benefits associated with the consumption of milk/dairy foods detailed in the evidence statements relate equally to reduced-fat and regular fat products.

Key points from Dairy Australia’s submission on the draft Australian Dietary Guidelines (NHMRC, 2011)

 

  • There is no evidence in the food specific evidence statements supporting the view that reduced-fat milk, cheese or yoghurt are healthier than regular fat ones.
  • All of the health benefits associated with the consumption of milk, yogurt and cheese outlined in the evidence statements relate equally to reduced-fat and regular fat products.
  • Dairy Australia commissioned CSIRO to undertake dietary modelling using similar methods to the Food Modelling document.  This new CSIRO dietary modelling (Riley, 2012) demonstrates that a food intake pattern CAN be selected where core dairy food intake is entirely or predominantly from the medium fat and high fat dairy food categories which is nutritionally equivalent or superior to the draft AGHE recommendations for energy and the 10 key ‘driver’ nutrients.  
  • Dairy Australia presented an evaluation of the evidence against the five key evidence streams which the NHMRC drew upon in developing the Guidelines, which demonstrates that the ‘mostly reduced-fat’ advice for milk, yogurt and cheese should be omitted
    • The ‘mostly reduced-fat’ advice may fit with the modelling but is not consistent with the Evidence Report.
    • Omitting the ‘mostly reduced-fat’ phrase from the Guideline wording makes the guideline more scientifically accurate because it more accurately reflects the dairy foods evidence statements while (as the CSIRO modelling (Riley 2012) demonstrates) also fitting in with the Modelling parameters.
    • A key authoritative report, the 2010 FAO/WHO Expert Consultation on Fats and Fatty Acids in Human Nutrition, did not specify ‘mostly reduced-fat’ for core dairy foods in its food-based dietary guidelines recommendations.   
    • On the basis of the points discussed above, Dairy Australia recommends that the draft Australian Dietary Guideline on dairy foods be revised to read as follows:

      Milk, yogurt, cheese and/or alternatives (reduced-fat milks are not suitable for children under 2 years).

       

      This amendment represents an incremental development from the 2003 Dietary Guidelines, reflecting a body of recent scientific knowledge, i.e. it is not a revolutionary change from the previous Guidelines.

 

 

Further details presented in Dairy Australia’s submission to the NHMRC on the draft Dietary Guidelines are provided in Appendix 1.

Moreover, of particular relevance to this consultation there is NO evidence that consuming reduced-fat core dairy foods leads to a lower risk of weight gain, overweight or obesity.

  • In a 2011 systematic review of prospective cohort studies to assess the longitudinal relationship between habitual dairy consumption and the risk of overweight/obesity consumption of dairy foods showed no harmful effect on weight status, in either children or adults (Louie et al., 2011).  Moreover, contrary to popular belief, low-fat dairy products were not found to be more beneficial to weight status than regular fat dairy products.  In fact, the reverse may be true.  The paper concludes ‘In summary, there is currently insufficient evidence to conclude that increased dairy consumption, particularly of regular fat varieties, is associated with weight status.
  • No relationship was found between consumption of either whole milk, or low fat/skim milk or cheese and weight gain in a 2011 pooled analysis of data from three prospective cohort studies in which the dietary intake of 120,877 US men and women was followed for 12 years or 20 years (Mozaffarian et al., 2011). (In contrast, of all the foods, yogurt consumption was associated with the greatest decline in body weight – four times as much weight loss as a serving of vegetables and one-and-a-half times as much weight loss as a serve of fruit).
  • Hendrie and Golley (2011) observed that changing from regular fat dairy foods to reduced-fat varieties had no effect on total energy intake or adiposity measures (BMI, BMI z-score or waist circumference) in a 24 week randomised controlled trial in Australian children. 

 

Under PART C – CHILDREN AND ADOLESCENTS 13.2 Supporting Weight Management. Case studies – supporting weight management in children

Case Study 12*

“…..and dietary habits put her at risk of weight gain (skipping breakfast, snacking and consuming full-cream milk and soft drink)……..”

There is NO evidence to support that consuming full-cream or regular fat milk is a dietary habit that increases risk of weight gain. To describe consumption of regular milk in this context is inappropriate. Milk is a nutrient rich core food that makes a valuable contribution to the diet. As described on the previous page, the dietary modeling conducted for the draft Australian Dietary Guidelines included regular fat milk.   

A recent Australian study (Hendrie & Golley, 2011) is the first randomised controlled study to assess the effects of changing from regular-fat to reduced-fat dairy foods (as the only intervention) on dietary intake. 

Methods

A 24 week cluster randomised controlled trial was conducted in children (4 to 13 years) to test the effects of changing from regular-fat dairy foods to reduced-fat varieties on dietary intake, metabolic and anthropometric outcomes.  The parents of the intervention group received individualised nutrition education from a research dietitian about the importance of dairy foods for children and the need to change their children from regular to low fat dairy foods.  The parents in the control group received individual advice by a research dietitian about reducing children’s screen time and replacing it with other sedentary activities.  These parents were given no specific dietary or dairy specific education and were encouraged to continue with their usual dietary pattern.  Parents were given their advice by the research dietitian during 30 minute appointments during weeks 1, 5 and 9.   Measurements were taken at baseline, at the end of the 12 week intervention, and 12 weeks later. 

Results

145 children from 93 families participated in the study and the children in the intervention successfully changed their dairy intake – regular fat dairy foods decreased from 88% to 18% of dairy intake in the intervention group at 24 weeks.  As would be expected, this led to a significant decrease in saturated fat intake by the intervention group – intake was 3.3 percentage points lower in the intervention group at week 24 compared with the control group.  However, carbohydrate intake (% energy) increased in the intervention group – intake was 4.1 percentage points higher in the intervention group at week 24 compared with the control group.  (Absolute amounts of carbohydrate were not significantly different). 

Importantly, changing from regular fat to reduced fat dairy foods had no effect on total energy intake or adiposity measures (BMI, BMI z-score or waist circumference). 

Moreover, the fact that saturated fat was replaced by carbohydrates may have even increased risk of CHD, particularly if the carbohydrates were refined.  The 2011 FAO/WHO expert consultation on ‘Fats and fatty acids in human health’ concluded that ‘there is probable evidence that replacing SFA with largely refined carbohydrates has no benefit on CHD and may even increase the risk of CHD and favour metabolic syndrome development.’   

The observation that switching from regular-fat dairy foods to low-fat types did not lead to an overall decline in energy intake is very important.  Clearly, the children compensated for the reduced energy within their dairy foods by consuming other foods.  This suggests that the basis for recommending people simply switch from regular-fat dairy foods to reduced-fat varieties in order to help reduce obesity is flawed. It also supports the results from prospective cohort studies suggesting there is no advantage of reduced-fat dairy foods over regular-fat versions for weight gain – both are unrelated to weight gain. 


SIGNIFICANT RECENT EVIDENCE IN RELATION TO DAIRY FOODS, ENERGY INTAKE AND BODY WEIGHT.

A study by Mozaffarian et al (2011) monitored the dietary intake of 120,877 US men and women over a long period of time (12 years or 20 years).  At the start of the study, none of the subjects were obese or had any chronic diseases.  Within each four-year period participants gained an average of 3.35lb (1.5 kg) which corresponds to a weight gain of 16.8lb (7.3 kg) over 20 years.

After adjustment for all relevant factors, they reported that of all the foods, yogurt consumption was associated with the greatest decline in body weight. 

Foods associated with weight loss

4 year weight gain per serving per day

Yogurt

-0.82 lb

Nuts

-0.57 lb

Fruits

-0.49 lb

whole grains

-0.37 lb

Vegetables

-0.22 lb

Note that a serving of yogurt was associated with four times as much weight loss as a serving of vegetables and one-and-a-half times as much weight loss as a serve of fruit. 

In terms of drinks, sugar sweetened beverages and fruit juice were both associated with weight gain whereas there was no relationship between consumption of low fat/skim milk or whole milk and weight gain.  Cheese also had a neutral effect on weight. 

Foods associated with the greatest weight gain were potato chips, French fries, sugar-sweetened drinks, unprocessed red meats and processed meats. 

Whereas the New England Journal of Medicine pooled data from three large US cohort studies, a new Australian systematic review (Louie et al, 2011) examined the entirety of the scientific literature for prospective, cohort studies that have reported on the relationship between dairy intake and weight gain/obesity.   

 According to the authors, this is the first systematic review of prospective cohort studies to assess the longitudinal relationship between habitual dairy consumption and the risk of overweight/obesity.

The systematic review makes clear that consumption of dairy foods showed no harmful effect on weight status, both in children and adults and that contrary to popular belief, low-fat dairy products were not found to be more beneficial to weight status than regular-fat dairy products.  In fact, the reverse may be true. 

The paper concludes ‘In summary, there is currently insufficient evidence to conclude that increased dairy consumption, particularly of regular-fat varieties, is associated with weight status.

These findings, that regular-fat dairy foods such as cheese and whole milk are not associated with weight gain, are remarkably consistent with those from the New England Journal of Medicine paper described earlier.

The above two studies provide no evidence that consumption of regular-fat dairy foods is associated with weight gain/obesity.  However, as they are observational, cause and effect cannot be determined.  For this, randomised controlled trials are required. 

A recent Australian study (Hendrie & Golley, 2011) is the first randomised controlled study to assess the effects of changing from regular-fat to reduced-fat dairy foods (as the only intervention) on dietary intake. 

Methods

A 24 week cluster randomised controlled trial was conducted in children (4 to 13 years) to test the effects of changing from regular-fat dairy foods to reduced-fat varieties on dietary intake, metabolic and anthropometric outcomes.  The parents of the intervention group received individualised nutrition education from a research dietitian about the importance of dairy foods for children and the need to change their children from regular to low fat dairy foods.  The parents in the control group received individual advice by a research dietitian about reducing children’s screen time and replacing it with other sedentary activities.  These parents were given no specific dietary or dairy specific education and were encouraged to continue with their usual dietary pattern.  Parents were given their advice by the research dietitian during 30 minute appointments during weeks 1, 5 and 9.   Measurements were taken at baseline, at the end of the 12 week intervention, and 12 weeks later. 

Results

145 children from 93 families participated in the study and the children in the intervention successfully changed their dairy intake – regular fat dairy foods decreased from 88% to 18% of dairy intake in the intervention group at 24 weeks.  As would be expected, this led to a significant decrease in saturated fat intake by the intervention group – intake was 3.3 percentage points lower in the intervention group at week 24 compared with the control group.  However, carbohydrate intake (% energy) increased in the intervention group – intake was 4.1 percentage points higher in the intervention group at week 24 compared with the control group.  (Absolute amounts of carbohydrate were not significantly different). 

Importantly, changing from regular fat to reduced fat dairy foods had no effect on total energy intake or adiposity measures (BMI, BMI z-score or waist circumference). 

Moreover, the fact that saturated fat was replaced by carbohydrates may have even increased risk of CHD, particularly if the carbohydrates were refined.  The 2010 FAO/WHO expert consultation on ‘Fats and fatty acids in human health’ concluded that ‘there is probable evidence that replacing SFA with largely refined carbohydrates has no benefit on CHD and may even increase the risk of CHD and favour metabolic syndrome development.’   

The observation that switching from regular-fat dairy foods to low-fat types did not lead to an overall decline in energy intake is very important.  Clearly, the children compensated for the reduced energy within their dairy foods by consuming other foods.  This suggests that the basis for recommending people simply switch from regular-fat dairy foods to reduced-fat varieties in order to help reduce obesity is flawed.

It also supports the results from prospective cohort studies suggesting there is no advantage of reduced-fat dairy foods over regular-fat versions for weight gain – both are unrelated to weight gain. 

 

A number of different mechanisms have been suggested to explain dairy’s neutral effect on body weight (e.g. lipolysis, lipogenesis and fecal fat loss).  Recently, Gilbert and colleagues (2011) have suggested that dairy foods may also have a beneficial effect on appetite regulation. 

This new study examined how milk may help obese women control their appetite during a weight loss diet.  All the women recruited for the study had a low habitual calcium intake (less than 800mg/d).  They were randomised to consume an energy restricted diet (-2508 kJ/d) that included either 568ml milk (providing 1000mg calcium) or an isoenergetic placebo (calcium-free rice drink). 

After 6 months, both groups showed significant weight loss, but in the milk group the weight loss induced a smaller increase in the desire to eat and hunger.  This result remained significant after adjustment for weight loss.

The authors concluded that including milk supplementation in an energy-restricted diet reduced the women’s weight loss-related increase in appetite.  They suggested that this effect was due to the calcium and protein present in the milk supplement. 

As approximately 60% of Australian women, like the women in this study, have a habitual calcium intake below 800mg/d, correcting low calcium intake by encouraging consumption of at least 3 daily serves may really help to reduce weight-loss induced appetite. 

Sometimes it is incorrectly assumed that soy drinks are nutritionally equivalent to dairy foods.  This new study compared the effects of soy drink and milk on fat loss.  

Faghih Sh et al., (2011) randomised subjects to one of four different weight loss diets (500kcal energy deficit) for 8 weeks: a control diet containing 500-600mg calcium, a calcium carbonate-supplemented diet, a diet including 3 servings of milk and a diet containing 3 servings of calcium fortified soy beverage.  Calcium intake during the study period was about 500mg for the control diet and 1315mg for the other three diets. 

At the end of the study, weight change (% of initial) in the high milk group was significantly greater than in the soy beverage group (p<0.05) and the controls. 


Diet

Weight change (% of initial)

Control (500-600mg Ca)

3.80

Calcium carbonate supplemented (800mg Ca)

4.80

Diet with 3 serves of milk

5.80

Diet with 3 serves of soy beverage (calcium fortified)

4.31

The researchers concluded that the greatest changes were seen in the high dairy group.  These results highlight the superiority of dairy foods to calcium provided from fortified foods and supplements for weight loss. 

 

In summary, these recently published papers outline some important developments in our understanding of the effects of dairy foods on body weight, overweight and obesity.  Together they suggest that:

  • Dairy foods may help with appetite control
  • For weight loss, dairy foods are superior to other sources of calcium (e.g. supplements and soy drink). 
  • Regular-fat dairy foods have a neutral effect on weight – they are not the foods to cut out.
  • Swapping from regular-fat to reduced-fat dairy products may not lead to reduced overall energy intake. 
  • For dairy, it is best to focus on quantity rather than type i.e. ensuring an adequate dairy intake (3 serves) rather switching from regular to reduced fat varieties. 
  • Yogurt should be top of mind for inclusion in weight loss diets.  In the long term, yogurt consumption was associated with greater weight loss than foods such as fruit, vegetables and whole grains.

What’s important is to encourage individuals to consume at least three serves every day of the type of milk, yogurt and cheese they like best.

 

 

 


References:

Doidge JC & Segal L (2012) Most Australians do not meet recommendations for dairy consumption: findings of a new technique to analyse nutrition surveys.  Aus NZ J Pub Health (In Press)

Faghih Sh et al (2011) Nutrition, Metabolism and Cardiovascular Diseases 21, 499-503.

FAO (2010) Food and Nutrition Paper 91.  Fats and fatty acids in human nutrition.  Report of an expert consultation.  Available at http://foris.fao.org/preview/25553-ece4cb94ac52f9a25af77ca5cfba7a8c.pdf

Gilbert J et al (2011) Milk supplementation facilitates appetite control in obese women during weight loss: a randomised, single-blind, placebo-controlled trialBritish Journal of Nutrition 105, 133-43.

Hendrie GA, Golley RK (2011)  Changing from regular-fat to low-fat dairy foods reduces saturated fat intake but not energy intake in 4-13-y-old children.  American Journal of Clinical Nutrition; 93,1117-27.

Louie JYC, Flood VM, Hector DJ, Rangan AM & Gill TP (2011) Dairy consumption and overweight and obesity: a systematic review of prospective cohort studies. Obesity reviews (7): e582-92.

Mozaffarian D et al., (2011) Changes in diet and lifestyle and long term weight gain in women and men.  New England Journal of Medicine 364, 2392-404.

NHMRC (2011) draft Australian Dietary Guidelines.

Riley MD (2012). Modeling regular fat dairy food in a nutritious diet. CSIRO, Australia.

 

 

Appendix 1

 

 

 

Key Comments from Dairy Australia on the draft Australian Dietary Guidelines (submitted to NHMRC, February 2012)

 

 

1      Issue 1: Lack of evidence to specify ‘mostly reduced-fat’ for milk, yogurt and cheese in Guideline 1

The first, and most important issue for Dairy Australia is the recommendation that milk, yogurt and cheese should be ‘mostly reduced-fat’.  In our submission, we presented two arguments for why, according to the systems put in place to develop these Dietary Guidelines, the advice that milk, yogurt and cheese should be ‘mostly reduced-fat’ cannot be defended. 

The approach correctly taken by the Working Committee is a food rather than isolated nutrient approach. 

What is the justification for ‘mostly reduced-fat?

The box below reproduces the justification provided for the advice that milk, yogurt and cheese are ‘mostly reduced-fat’ within the Draft Dietary Guidelines and the Food Modelling document.

Draft Dietary Guidelines page 62

2.5.1 Setting the scene

The proportion of total fat and saturated fat content in some milk, cheese and yogurts has led to the recommendation that reduced-fat varieties should be chosen on most occasions (ref 10, i.e. the Food Modelling document)’

The Food Modelling document page 13

‘Dairy foods (milk, yogurt, cheese) were selected during modelling the Foundation Diets because they are major contributors to calcium and some other key nutrients.

However they can also contribute substantially to the saturated fat content of the diets.  Limitations were set for Foundation Diet models based on the evidence-based reviews relevant to chronic disease.’

Dairy Australia acknowledges that it is usual for reduced-fat milk, yogurt and cheese to be considered healthier than regular fat varieties.  However, after having examined the latest available scientific evidence at length, we do not agree with this position. 

Table 1 outlines the evidence statements for milk, yogurt and cheese – quoted directly from the draft Dietary Guidelines (pages 62-64) and indicates whether they apply to regular fat dairy foods and/or reduced-fat dairy foods. 

The two specific evidence statements (both Level C) relating to weight and BMI refer to ALL types of dairy foods and milk not exclusively reduced-fat.

From Table 1, it is apparent that out of the 12 evidence statements, only one specifies low fat dairy foods – the one for reduced risk of hypertension.  However, for hypertension, there is a second evidence statement stating that consumption of any milk, cheese or yogurt products a day is associated with reduced risk. 

Therefore, all of the health benefits associated with the consumption of milk, yogurt and cheese relate equally to reduced-fat and regular fat products.

There is no evidence in these food specific evidence statements supporting the view that reduced-fat products are healthier than regular fat ones.


Table 1 Fat content of dairy foods referenced in evidence statements

 Evidence Statement (level of evidence)

Applies to

Reduced- fat

Regular fat

Consumption of at least 2 servings per day of dairy foods (milk, yogurt and cheese) is associated with reduced risk of ischemic heart disease and myocardial infarction (B)

Yes

Yes

Consumption of 2 or more servings of dairy foods per day is associated with reduced risk of stroke (B)

Yes

Yes

Consumption of 3 servings of low fat dairy foods is associated with reduced risk of hypertension (B)

Yes

No

Consumption of 3 servings of any milk, cheese or yogurt products a day is associated with reduced risk of hypertension (C)

Yes

Yes

Consumption of more than 1 serving of dairy per day, especially milk, is associated with a reduced risk of colorectal cancer (B)

Yes

Yes

Consumption of 3 or more servings of milk per day is not associated with risk of renal cell cancer (C)

Yes

Yes

Consumption of 2-4 servings of dairy foods per day is associated with reduced risk of metabolic syndrome (C)

Yes

Yes

Consumption of at least 1.5 servings of dairy foods (milk, yogurt, cheese) per day is associated with reduced risk of type 2 diabetes (C)

Yes

Yes

Consumption of more than 1 serving of milk per day is associated with reduced risk of rectal cancer (C)

Yes

Yes

Consumption of dairy products (particularly milk) is associated with improved bone mineral density (C)

Yes

Yes

Consumption of dairy foods is not associated with weight change or risk of obesity in adults (C)

Yes

Yes

Consumption of milk is not associated with BMI or BMI change in childhood (C)

Yes

Yes

 

Does advice to consume ‘mostly reduced-fat’ milk, yogurt and cheese promote health and wellbeing? 

  • Higher levels of consumption of milk, yogurt and cheese are associated with a reduced risk of key chronic diseases (as outlined in the Evidence Statements);
  • 62% of Australians consume inadequate amounts (Doidge & Segal 2012) so miss out on key health benefits;
  • At least 5 studies demonstrate that most people prefer the taste of regular fat products over reduced-fat varieties (Buss & Worsley 2003, Brewer et al., 1999, Mela 1988, Richardson-Harman et al., 2000, Mela et al., 1993).  Figure 4 also indicates this;
  • The NHMRC’s own consumer focus group testing of the draft guidelines found some men considered milk was ‘not negotiable’ in that they always chose whole milk for the better taste (NHMRC, personal communication 2012).

 

Figure 1 Results of a Roy Morgan milk survey of 1,142 adults (14 yrs +) from 5 major Australian cities conducted in 2007 (Dairy Australia, 2007).

At least 5 studies (Bus & Worsley 2003a & b; Cashel et al., 2000; Brewer et al., 1999; French et al., 2008) indicate that frequently reported barriers to the consumption of regular fat core dairy foods are concerns about the fat and saturated fat content and weight gain.

For example:

  • Whole milk was perceived more negatively than reduced-fat milk in a survey of 345 randomly selected shoppers in Melbourne (Bus and Worsley 2003a).  The researchers suggested that most of the negative health perceptions were related to the fat content of whole milk.
  • Negative perceptions (e.g. high in fat, cholesterol and calories) were most common for whole milk compared with reduced-fat milk, and reduced-fat milk was perceived as being more ‘watery’ in a study of Australian consumers (Bus and Worsley 2003b). 
  • Concerns about fat were reported to be prejudicing the type of milk and amount of calcium consumed in a study of 300 Australian women (Cashel et al., 2000). 
  • Women liked whole milk significantly more than skimmed milk and 1% fat milk (P ≤ 0.05) however, significantly fewer believed that whole milk was good for them than for lower fat milks (P ≤ 0.05) in a study of 100 women living in the US (Brewer et al 1999).  The authors commented that the group as a whole, equated lower-fat (dairy) products with a more healthful product and that health concerns outweighed sensory concerns for milk drinkers. 
  • Concerns about weight gain and the fat content of calcium-rich dairy foods were the most frequently reported barriers to obtaining adequate calcium intakes in a prospective study identifying factors affecting adherence to recommended calcium intake in women with low bone mass (French et al., 2008).  

In the NHMRC’s own consumer focus group testing regular fat milk was considered an unhealthier option by the majority of consumers.

Advice to consume ‘mostly reduced-fatre-enforces the view that consumption of regular fat core dairy foods should be moderated.  Dairy Australia is particularly concerned that the Draft Dietary Guidelines advise adults to halve their consumption of higher fat varieties of milk, yogurt and cheese (page 66) and that this message was widely communicated in the media. 

There is no evidence that this is necessary from the evidence statements and such advice is likely to have a detrimental impact on some people’s overall intake of core dairy foods.  There is no evidence to support the view that consumers will maintain their overall core dairy consumption when they are advised to change to reduced-fat products.

Moreover, there is some direct evidence that advising people to switch from regular fat to reduced-fat core dairy foods leads to a decline in overall consumption of core dairy foods.

For example, in a recent Australian trial in which overweight adults were recommended to switch to reduced-fat dairy foods Nolan and colleagues observed that men  cut down on dairy foods rather than compromise on taste with reduced-fat dairy foods, consuming 9% less calcium from dairy (P=0.000) (Nolan et al, 2010).  Women were more adaptable and the fall in their calcium consumption was not statistically significant.

 

The authors concluded that given research demonstrating potential health benefits of dairy fat and possible detrimental affects of higher carbohydrate consumption, standard dietetic practice to recommend low-fat dairy products for overweight individuals may require reassessment.  

Overall, the scientific literature suggests that consumers face a dilemma between preferring the taste of regular fat core dairy foods over reduced-fat but that they are being dissuaded from consuming regular fat core dairy foods due to health concerns in relation to their perceived saturated fat and fat contents and weight gain.

Reducing the amount of dietary fat does not necessarily reduce dietary energy.  Mullie et al., (2012) recently reported that a higher consumption of low-fat foods was associated with a higher overall energy intake in a group of 1,852 men aged 20 to 59 years. Similarly, Gatenby et al., (1997) previously reported that an increase in low-fat foods was not associated with a reduction in total energy intake. As previously mentioned Hendrie & Golley (2011) observed that changing from regular fat dairy foods to reduced-fat varieties had no effect on total energy intake or adiposity measures (BMI, BMI z-score or waist circumference). 

In summary – advice to consume ‘mostly reduced-fat’ milk, yogurt and cheese is likely to have a negative impact on overall consumption, reducing people’s chances of meeting dairy recommendations and accessing the health benefits associated with adequate consumption.

 

References:

Brewer JL (1999) Theory of reasoned action predicts milk consumption in women.  Journal of the American Dietetic Association; 99: 39-44.

Bus AEM & Worsley A (2003a) Consumers’ health perceptions of three types of milk: a survey in Australia.  Appetite 40, 93-100.

Bus AEM & Worsley A (2003b) Consumers’ sensory and nutritional perceptions of three types of milk.  Public Health Nutr 6, 201-8.

Cashel KM et al., (2000) Milk choices made by women: what influences them, and does it impact on calcium intake?  Public Health Nutrition 3(4), 403-10.

Dairy Australia (2007) – Roy Morgan Research “ Project 2”.

Doidge JC & Segal L (2012) Most Australians do not meet recommendations for dairy consumption: findings of a new technique to analyse nutrition surveys.  Aus NZ J Pub Health (In Press).

French MR et al. (2008) A prospective study to identify factors affecting adherence to recommended daily calcium intake in women with low bone mineral density.  Journal of the American College of Nutrition 27, 88-95.

Gatenby S et al (1997) Extended use of foods modified in fat and sugar content.  Nutritional implications in a free-living female population.  Am J Clin Nut 65, 1867-1873.

Hendrie GA, Golley RK (2011)  Changing from regular-fat to low-fat dairy foods reduces saturated fat intake but not energy intake in 4-13-y-old children.  American Journal of Clinical Nutrition; 93,1117-27.

Mela DJ et al., (1993) No effect of extended home use on linking for sensory characteristics of reduced-fat foods. Appetite; 21:117-29.

Mela DJ (1998) Sensory assessment of fat content in fluid dairy products.  Appetite 10, 37-44.

Mullie P et al., (2012) Determinants and nutritional implications associated with low-fat food consumption.  Appetite; 58: 34-8.

NHMRC (2012) Personal communication relating to the findings of consumer focus testing of the draft Dietary Guidelines.

Nolan D. Tapsell L. Probst Y, Charlton K and Betterham M. (2010) Dietary outcomes and consequences of recommending low fat dairy products to overweight adults participating in a weight loss trial. Nutrition and Dietetics, 201:67(S1), pp 16.

Richardson-Harman NJ et al. (2000), Mapping consumer perceptions of creaminess and liking for liquid dairy products.  Food Qual Pref; 11: 3:239-46.

 

Page reviewed: 7 September, 2012