Organised once every four years, the 12th FENS European Nutrition Conference is being held this year in Berlin, from 20th to 23rd October. On this occasion, YINI is delighted to be part of the programme, hosting a symposium on a very topical subject: "Yogurt consumption benefits: global findings & perspectives". This insightful session, chaired by Prof Dr Raanan Shamir (Israel) and Andrew Prentice (UK), took place on Thursday 22th October, at 16.30 and was led by renowned experts in the fields of obesity, nutrition and diabetes! Dr Richard Atkinson He has worked in obesity research and treatment for over 40 years, is interested in obesity policy, and has advocated for young investigator programs nationally and internationally. His research includes causes and treatments of obesity, particularly obesity drugs, obesity surgery, and virus-induced obesity. His laboratory demonstrated that human adenovirus-36 produces obesity in animals and is associated with obesity in humans. In summary The York Health Economics Consortium and collaborators performed a comprehensive literature search identifying papers on yogurt and weight management. Selection criteria were studies of classical yogurt only, probiotic bacteria were excluded, as were studies on individuals with various diseases. From 13,000 potential papers, 69 met potential criteria and 22 were selected, including 7 cross-sectional, 6 cohort, 2 crossover, and 7 controlled trials. All cross-sectional and cohort trials showed a beneficial association of yogurt and one or more body weight/composition measures. Limitations were that all dietary data were self-reported, confounding variables not completely controlled, and correlation is not causation. Two crossover studies were small, short duration, and uninterpretable. Five of seven controlled trials had major limitations including self-report of intake, inadequate or irrelevant research design, few subjects, inadequate description, etc. One well controlled, randomized study had clear results showing a beneficial effect of yogurt, but improper design to address effects of yogurt alone. Five of six RCT showed a beneficial effect of yogurt, but only one was significant. Yogurt is a “health food” accepted by most people and has potential for prevention and treatment of overweight/obesity. Previous studies give optimism for yogurt for weight management, but future well-designed randomized, controlled trials for proof of principle and large population studies for feasibility are needed.

1. Yogurt and Weight Management:
New Insights on the Evidence
• Richard L. Atkinson, M.D.
• Executive Director
• Virginia Obesity Research Institute
• Richmond, Virginia, USA
Copyright: RL Atkinson, 2015

2. Conflicts of interest regarding this presentation:

3. THE GLOBAL EPIDEMIC
OF OBESITY
©

4. PREVALENCE OF OBESITY: USA%OBESE
TIME
0
10
20
30
40
1960 1970 1980 1990 2000 2004
NHANES, CDC ‘06
©

5. CDC: INCREASE IN CHILDHOOD OBESITY
©
©

7. Increase in prevalence of obesity in
Chinese children from 1989 to 1997
Obesity increased in urban children by over 8 fold
Luo and Hu; IJO ‘02

8. Global Prevalence of Obesity in Adult Females
South East Asia &
Pacific Region
Nauru 78%
Tonga 70%
Samoa 63%
Niue 46%
French Polynesia 44%
Africa
Seychelles 28%
South Africa 28%
Ghana 20%
Mauritania 19%
Cameroon (urban) 14%
South Central America
Panama 36%
Paraguay 36%
Peru (urban) 23%
Chile (urban) 23%
Dominican Republic 18%
North America
USA 33%
Barbados 31%
Mexico 29%
St Lucia 28%
Bahamas 28% Eastern
Mediterranean
Jordan 60%
Qatar 45%
Saudi Arabia 44%
Palestine 43%
Lebanon 38%
European Region
Albania 36%
Malta 35%
Turkey 29%
Slovakia 28%
Czech Republic 26%
% Obese
0-9.9%
10-14.9%
15-19.9%
20-24.9%
25-29.9%
≥30%
Self Reported
data
With examples of the top 5 Countries in each
Region
With the limited data available, prevalence's are not age standardised. Self reported surveys may
underestimate true prevalence. Sources and references are available from the IOTF.
© International Obesity TaskForce, London –January 2007

9. Increased weight of animals since 1980
Klimentidis & Allison et al. Proc Royal Soc Biol Sci ‘10
©

10. WHAT IS THE ETIOLOGY OF THE
GLOBAL EPIDEMIC OF OBESITY?
1. Rich countries and poor countries began
to get fat at the same time (around 1980)
2. The usual explanations of changes in diet
and activity patterns don’t explain the rise
3. The epidemic is also affecting pets (NAS
report, 2003; Klimentidis, 2010)
4. Something in the environment changed
©

11. CAUSES OF OBESITY:
PUBLIC PERCEPTON
“The Big Two”
Diet and Physical Activity:
Too much diet
Too little physical activity
Keith, Allison, et al IJO ‘05©

12. Alternate Explanations for Obesity
1. Epigenetics: Intrauterine/Intergenerational Effects
2. Obesity due to drugs
3. Sleep debt
4. Increasing age at first pregnancy
5. Decreased smoking
6. Distribution of ethnicity and age
7. Ambient temperature
8. Selection for obesity-predisposing genotypes
9. Assortative mating
10. Environmental pollutants, endocrine disruptors
11. Infectious causes of obesity (adenovirus 36)
Keith, Allison et al IJO ’05; McAllister et al Crit Rev Food Sci Nutr ‘09; Atkinson et al IJO ‘05
©

13. COMPLICATIONS OF OBESITY
• Diabetes mellitus Urinary incontinence
• Hypertension Reproductive dysfunction
• Dyslipoproteinemia Gout
• Cardiac disease High intra-abd pressure
• Cerebrovascular dis. Pseudotumor cerebri
• Pulmonary disease Adiposis dolorosa
• Cancer Pregnancy risks
• Gallbladder disease Surgery risks
• Degenerative arthritis Psychological disease
• Venous stasis, edema Socio-economic troubles
• GERD Premature mortality
©

14. YEARS OF LIFE LOST DUE TO
SEVERE OBESITY (BMI > 45)
For ages 20-30:
Males Females
White 13 8
Blacks 20 5
• Fontaine et al, JAMA 289:187-193, 2003
©

15. Costs of Obesity
Annual Medical Costs: $160 billion
Indirect cost of obesity: $460 billion
Top-Nursing-Programs.com
©

16. ©
Yogurt and Weight Management

17. Weight Management with L. reuteri
Poutahidis et al, PLoS One, 2013 (Jul 10;8:e68596)
L reuteri was added to the drinking water for 3 months (age
2-5 months) and prevented weight gain on both control cow
and high density chow containing high fat and sugar (a).
Calorie intake was similar among groups (f).

18. ©
RCT: Effect of Lactobacillus rhamnosus
CGMCC1.3724 supplementation on weight
loss and maintenance in obesity
Sanchez et al, Br J Nutr, 2014
No overall effect on weight or fat, but significant
effect in women at 24 weeks:
Females only:
LPR Group Placebo group
Body weight (kg) -5.2 + 4.00* -2.50 + 3.50
Fat mass (kg) -4.70 + 3.60* -2.16 + 4.11
*p<.05

19. Yogurt and Weight: Systematic Review*
1. Only yogurt studies considered
Definition of yogurt:
Fermented milk that contains symbiotic
cultures of Streptococcus thermophilius
and Lactobacillus delbrueckii, subspecies
Bulgaricus
2. Probiotic preparations were not considered
3. Only apparently healthy adults age18-65 yr
*Literature search and analysis by York Health Economics Consortium
*Funding support from Danone Institute International
Accepted, Int J Obesity, 30 Sept, 2015 ©

20. Yogurt and Weight:
Systematic Review
• Weight management outcomes:
• Body weight
• Body Mass Index (BMI)
• Waist circumference (WC)
• Fat mass
• Lean body mass
©

21. Yogurt and Weight:
Systematic Review
22 studies in this systematic review:
• 6 Randomized controlled trials
• 1 Controlled trial
• 2 Non-randomised cross-over trials
• 6 Cohort studies
• 7 Cross-sectional studies
©

22. Yogurt and Weight:
Cross-Sectional Studies
Cross-sectional studies: lower grade of
evidence
• One prospective, 6 retrospective studies (3
were abstracts)
• Populations: 720-14,618 subjects
• Self reported dietary data
• Results: All studies showed a beneficial
association of yogurt and one or more body
weight/composition measures
©

23. Obesity and Dairy Consumption
Beydoun et al; AJCN 87:1914-1925 , 2008
Cross-sectional study of 14,618 NHANES subjects
(self report food intake data)
Odds ratio of obesity (BMI):
Odds Ratio p value
Whole milk 0.97 NS
Low fat milk 1.01 NS
Skim milk 0.98 NS
Cheese 1.12 <.05
Yogurt 0.57 <.05
©

24. ©
Yogurt and Weight:
Cross-Sectional Studies
Post Systematic Review
3 additional studies identified:
• Cormier et al, Eur J Nutr, 2015
• Keast et al, Nutrients 2015
• Sayón-Orea et al, BMC Pub Health, 2015
All three studies showed a positive effect on
body weight, fat, or %fat
In 10 of 10 cross-sectional studies, yogurt is
associated with beneficial status

25. Yogurt and Weight:
Cross-Sectional Studies
Limitations:
• All dietary data were self-report
• Confounding variables not completely
controlled
• Cross-sectional studies can only show
correlation, not causation
©

26. Yogurt and Weight: Cohort Studies
Cohort Studies: lower grade of evidence
• One prospective, 5 retrospective
• Populations: 248 to >120,000 subjects
• Self reported dietary data
• Results: All studies showed a beneficial
association of yogurt and one or more body
weight/composition measures
• In several studies yogurt was the only dairy
product associated with a favorable body
weight/composition
©

27. Yogurt and Weight: Cohort Studies
Limitations:
• All dietary data were self-report
• Confounding variables not completely
controlled
• Cohort studies can only show
correlation, not causation
©

28. Yogurt and Weight: Cohort Studies
Martinez-Gonzalez et al, Nutr Metab Cardiovasc Dis. 24:1189-96, 2014
1. Prospective cohort study: 8516 subjects followed 6.6 yr,
divided into categories of yogurt consumption
2. High yogurt consumers (>7/wk) had lower obesity
a. Total yogurt HR: 0.80
b. Full fat yogurt HR: 0.62
Figure 1: Hazard Ratio (HR) and 95%
CI of incident overweight/obesity
according to baseline frequency of
total yogurt consumption stratified by
low or high fruit consumption
(under/above the median).
©

29. ©
Yogurt and Weight: Cohort Studies
Mozaffarian et al, NEJM 364:2392, 2011
Figure 1. Relationships between
Changes in Food and Beverage
Consumption and Weight Changes
Every 4 Years, According to Study
Cohort.
Summary:
1. Retrospective cohort study of
120,877 health professionals
followed for three 4-year periods.
2. Self report dietary data
3. Yogurt showed the highest
correlation with favorable body
weight change of any food.
Greater yogurt intakes were
associated with weight loss over
time.

30. ©
Higher dairy consumers were much less likely to be black and somewhat
more likely to be women. Notably, dairy consumption was positively
associated with whole grain, fruit, vegetable, saturated fat intake, and
inversely associated with sugar-sweetened soft drink intake.
Differences in Dairy Intake by Race and Body Weight Category
Pereira et al, JAMA 287:2081-9, 2002
→ ←

31. Yogurt and Weight: Crossover
Studies
Two crossover studies: Not relevant
• Small numbers: 18-20 subjects
• Brief follow up time: 1-4 weeks
• Low fat yogurt only in one study
• In both studies the primary outcome was
effect on lipids levels, not body
weight/composition. Design and time of
trials not adequate to assess obesity/weight
measures
©

32. ©
Randomized Controlled Trials: highest grade of evidence
1. Six RCTs and one controlled trial. One report in abstract
only.
2. Five of the six studies had major limitations: abstract
only, inadequate or irrelevant research design, low
subject number, inadequate description, other problems
3. One well controlled study with clear results, but improper
design to address effects of yogurt alone
4. All studies had self reported dietary data
5. Results: Significant beneficial association of yogurt in
one study. 4 of 5 others showed yogurt more favorable,
but not significant
Yogurt and Weight:
Randomized Controlled Trials

33. ©

34. ©
1. 38 subjects randomized into 2 groups:
a. Control (N=16): 500 mg/d calcium, gelatin pack
b. Yogurt (N=18): 1100 mg/d calcium, 3 yogurt/d
2. 500 kcal/d deficit in both groups, diet diaries
3. 27 Females, 7 Males; Mean BMI = 32.6 kg/m2
4. Weekly visits for 12 week treatment period
5. Body composition by DEXA pre and post
RCT: Zemel et al, IJO, 2005
Research Design

35. ©
RCT: Zemel et al, IJO, 2005
Results
Difference in weight (kg)
-1.6 kg
Difference in body fat (kg)
-1.7 kg
Difference in LBM (kg)
+.61 kg

36. ©
RCT: Zemel et al, IJO, 2005
Results
Difference in Trunk fat (kg)
-1.4 kg
Difference in WC (cm)
-3.4 cm

37. ©
RCT: Zemel et al, IJO, 2005
Conclusions
1. Robust data showing yogurt associated with a
greater weight/body fat loss vs control
2. No conclusion can be made if yogurt was
responsible due to research design flaw that
both yogurt and calcium varied in study
3. Other studies show calcium has a modest
effect on body weight, so we can speculate that
yogurt produced the majority of weight/fat loss

38. ©
Systematic Review: Summary
1. The number of papers on yogurt for body
weight/composition is surprisingly small and many
studies are of poor quality
2. Cross-sectional and cohort studies almost all show a
positive association of yogurt and wt/fat but only
correlation, not causation
3. 5 of 6 RCTs showed a slight (NS) benefit of yogurt,
but research designs were inadequate
4. One RCT is very promising, showing a robust
benefit of yogurt on fat/wt in obesity, but confounded
by different calcium intake in groups
5. Modest evidence that full fat yogurt/dairy is more
beneficial for body weight/composition (prevention)

39. ©
Systematic Review: Conclusions
1. We cannot draw firm causation conclusions on
the basis of current evidence
2. The evidence is suggestive that yogurt as part
of a weight maintenance or weight loss
program will have a benefit
3. The degree of benefit is modest, about 1-2 kg
4. Studies have not adequately assessed the
effects of low vs full fat yogurt

40. ©
Yogurt and Weight: Future Research
• 1. There are sufficient cross-sectional and cohort
studies so further studies may not be productive
• 2. Future studies should be RCTs to prove proof of
principle, blinded to investigators where possible
• 3. Critical to have adequate numbers and follow up
• 4. Critical to include an assessment of effectiveness
of low fat vs high fat yogurt
• 5. Important to assess the mechanisms: gut bacteria
changes, dairy proteins, calcium, gut hormones,
fatty acids
• 6. Studies in both adults and children are needed

41. ©
Yogurt and Weight:
Health and Economic Consequences
Yogurt holds great promise, not to cure obesity, but
to be a simple measure that health professionals,
governmental agencies like IOM and USDA, and
policy makers can support that will assist in losing
weight or preventing weight gain as part of daily
life. Adding yogurt to as a lifestyle habit is not as
intrusive as exercise, diet pills, or more
complicated and rigid diets.

42. ©
Yogurt and Weight:
Health and Economic Consequences
• The health and economic consequences of
adding yogurt to the diet for an individual may be
modest, probably only 1-2 kg weight loss or
modest prevention of weight gain. However, on a
population health basis, such a difference could
produce large economic gains.
• We may speculate that the adoption of a “healthy
diet” that requires little of individuals may
stimulate other healthy lifestyle changes that may
have benefits beyond that of yogurt itself.

43. ©
THANKS
• Irene Lenoir-Wijnkoop
• Ana Pires
• Jacqui Eales
• Julie Glanville
• Andrew Prentice
• Raanan Shamir
• Frans Kok
• Nathalie Rolf-Pedersen

44. ©
FOR FURTHER INFORMATION
Richard L. Atkinson, M.D.
Virginia Obesity Research Institute
Richmond, Virginia
804-244-9070
richard.atkinson@vcuhealth.org