Is yogurt associated with reduced cardiometabolic risk factors in

children?

Dr André MaretteLaval Hospital, Heart and Lung Institute, Institute for Nutrition and Functional Foods (INAF),Université LavalQuébec, Canada

Is yogurt consumption associated with reduced

cardiometabolic risk in children

Divulgation of potential conflicts

Consultation and honorarium• Danone Nutricia• Thetis Pharma• Valbiotis

Funding• CIHR, CDA, HSFC, FRQ, CRIBIQ • JA DeSève Fondation • Pfizer (Chair CIHR/industry)• Danone Nutricia• Thetis Pharma• Fédération des Producteurs Acéricoles du Québec• Dairy Farmers of Canada

“Toxic” food and unhealthy lifestyle

Cardiometabolic diseases

Diet-related diseases Prevalence of “severe”

obesity is increasing in children

Putting children at risk for “adult” diseases Type 2 diabetes Dyslipidemia Hypertension Metabolic syndrome

Preventable and manageable Healthy diet and lifestyle

behaviors learned in childhood

Kumar and Kelly (2017) Mayo Clinic Proceedings

What makes yogurt an interesting research topic?

High quality protein growth and maintenance of muscle mass

Source of Ca, vitamin D and P contribute to bone health

Nutrient rich food profile contributes to intakes of essential nutrients for health

Lipids and lactose energy source

Pairs well with other healthy foods potential for increased intake of fruits, vegetables and grains

Source of bioactive lipids and peptides di- and tri-peptides, CLA, short- and medium-chain fatty acids that contribute to protection against cardiometabolic risk factors

Live cultures improve lactose tolerance, increase concentrations of some nutrients (eg. CLA and bioactive peptides)

Number of publications on “yogurt” indexed in PubMed over the last 100

years

Total = 3296Probiotic yogurt = 644Yogurt consumption = 837Yogurt and weight = 431Yogurt and health = 897Microbiota and yogurt = 92

Macronutrient profile of common yogurts

Children aged 4-6 y

Children aged 7-11 y

Percent contribution of 100 g of commonly consumed yogurts to the reference nutrient intakes for energy, fat, carbohydrates and protein in children.

Based on the dietary reference values for children from the British Nutrition Foundation and Public Health England Composition of foods integrated dataset

% RNI

% RNI

Melissa Fernandez, Mauro Fisberg, and André MaretteChapter: Role of yogurt in the nutrition and health of children and adolescents. In book entitled "Yogurt in Health and Disease Prevention". Ed. Nagendra Shah, Elsevier 2017 In press

Yogurt’s contribution to the dietary reference values for

mineral and vitamin in children and adolescents

• Excellent source of iodine, vitamin B12, phosphorus, calcium, riboflavin and thiamin for children and adolescents

• Source of folate, magnesium, potassium and selenium

• Provides negligible amounts of iron, niacin and vitamin B6

• Concentrated source of nutrients for children

• Yogurt is an excellent vehicle for vitamin D fortification

Thiam

in

Riboflavin

B12Fo

late

Calcium

Phosphorus

Magnesi

um

Potasium

Selen

iumIodine

0

5

10

15

20

25

30

35

40

45

50

4-6 yo 7-10 yo11-14 yo15-18 yo

Based on the dietary reference values for children from the British Nutrition Foundation and Public Health England Composition of foods integrated dataset

% contribution of 100g low-fat fruit yogurt

IS YOGURT CONSUMPTION ASSOCIATED WITH BODY WEIGHT

GAIN IN CHILDREN AND ADOLESCENTS?

Long-term association between dairy consumption and risk of childhood

obesity: a systematic review and meta-analysis of prospective cohort studies

(Lu et al. Eur. J. Clin. Nutr. 2016)46 011 children and adolescents with an average 3-year follow-up

38% less likely to havechildhood overweight/obesity

the risk of overweight/obesity was 13% lower with

each serving of dairy/day

Association between yogurt consumption and adiposity

indicators in children (Zhu et al. Eur J Nutr. 2015)

Variable N Difference P - value

Body weight 4,370

-0.3 kg 0.65

BMI 4,342

0.1 kg/m2 0.64

Waist circumference

4,278

-0.2 cm 0.76

33%

67%

Frequency of yogurt consumption in a cohort of American children 2-18 y (NHANES 2003

and 2006)

Frequent yogurt consumers (at least once a week; median = 2/week)

Infrequent yogurt consumers (less than once a week; median = 1-6/year)

No differences in adiposity indicators between frequent and infrequent yogurt consumers

Association between yogurt consumption and obesity among U.S. Children aged 8–18 years

(Keast et al, Nutrients 2015)

Variable N Difference P - value

Body weight 3786 -1.7 kg NSBMI 3786 -0.7 kg/m2 <0.05Waist circumference

3786 -2.5 cm <0.05

9%

92%

Frequency of yogurt consumption in a cohort of American children 8-18 y (NHANES 2005-

2008)

Frequent yogurt consumers (at least once out of 2 24-h dietary recalls)

Non yogurt consumers (not at all men-tioned in 24 hour dietary recalls)

Significantly lower BMI and waist circumference in yogurt consumers compared to non-consumers

IS YOGURT CONSUMPTION ASSOCIATED WITH

CARDIOMETABOLIC RISK FACTORS IN CHILDREN AND ADOLESCENTS?

Systematic review of the associations between dairy product consumption and risk of cardiometabolic outcomes in the

adult population (Drouin-Chartier et al. Adv Nutr 2016)

Association between yogurt consumption and the lipid profile in

U.S. children (Zhu et al. Eur J Nutr. 2015)

Variable N Difference

P - value

Total cholesterol 3,272 -2.2 mg/dL

0.17

HDL cholesterol 3,272 -1.3 mg/dL

0.06

LDL cholesterol 1,265 -0.2 mg/dL

0.94

Triglycerides 1,266 -0.5 mg/dL

0.93

Non-HDL cholesterol 3,272 -0.9 mg/dL

0.58

Ratio of total cholesterol to HDL cholesterol

3,272 0.01 0.84

Differences in lipid profiles between frequent and infrequent yogurt consumers (children 2-18 y)

No differences in the lipid profile between frequent and infrequent yogurt consumers

Association between yogurt consumption and blood prsssure in

U.S. children (Zhu et al. Eur J Nutr. 2015)

Variable N Difference P - valueSystolic 2,868 -0.5 mmHg 0.45Diastolic 2,868 -1.6 mg/dL 0.11

Differences in blood pressure between frequent and infrequent yogurt consumers (children 2-18 y)

No differences in blood pressure between frequent and infrequent yogurt consumers

Associations between yogurt consumption and type 2 diabetes

risk factors in U.S. children (Zhu et al. Eur J Nutr. 2015)

Variable N Difference P - value

Glucose (mmol/L) 930 -0.02 mmol/L

0.64

Insulin (pmol/L) 913 -13.6 pmol/L

<0.001

HOMA-IR (homeostatic model assessment of insulin resistance)

913 -0.61 <0.001

QUICKI (Quantitative insulin sensitivity check index)

913 0.007 mg/dL

0.03

Differences in type 2 diabetes risk factors between frequent and infrequent consumers (children 2-18 y)

Significantly better metabolic profiles in frequent consumers compared to infrequent yogurt consumers

What could be driving these associations?

• Increase satiety and reduce short-term food intake

• Reduced appetite sensations• Increased gastric transit time

• Enhanced calcium transport• Insulintropic• Decrease plasma cholesterol,

triglycerides and fatty acids• ACE inhibitory bioactive peptides (blood

pressure control)

• Improved insulin sensitivity and blood glucose control

• PPAR agonist• Enhanced transport of fat soluble vitamins• Adipocyte cell differentiation inhibition• Anti-inflammatory• Plaque formation inhibition• Anti-obesogenic

• Decreased food intake and increased energy expenditure

• Increased fat-cell oxidation• Increased fat cell breakdown

• Anti-atherosclerotic• Anti-hyperlipidemic

• Normalize glucose tolerance and insulin secretion

• Reduced vascular smooth muscle intracellular calcium (lower blood pressure)

• Improved energy regulation and lipid storage

• Decreased fatty acid synthesis• Increased lipolysis

• Fecal fatty acid excretion• Induction of thermogenesis• Calcium-specific appetite control

• Improved nutrient bioavailability and digestion

• Increased PH• Increased concentration of CLA• Increased gut transit time

• Formation of smaller curds

• Increased viscosity• Maintenance of gut microbiota• Release of bioactive peptides• Improved lactose digestion

Vitamins and minerals

(calcium and vitamin D)

Protein(whey and casein)

Fermented milk

(lactic acid bacteria)

Lipids(bioactive fatty acids)

Yogurt matrix

Bioactive peptides

Bioactive peptides can be released from milk proteins through three known mechanisms:

1) hydrolysis with digestive enzymes (e.g., pepsin, trypsin, and chymotrypsin) 2) fermentation with proteolytic starter cultures 3) proteolysis with enzymes derived from microorganisms

Korhonen, J Funct Foods 2009

Intestinal transit and energy balance regulationAmino acid/nutrient release and absorption

Regulation of the gut microbiota

Digestive system

Casein- and whey-derived bioactive peptides

• Anti-hypertensive by ACE inhibition

• Vasodilators release• Anti-thrombotic

Vascular system

• Macrophages stimulation

• Proliferation and maturation of immune cells

• Metabolic endotoxemia

Immune system• Sympathetic

nervous activity and energy expenditure

• Gut-brain axis and satiety signals

Nervous system• Anticholesterolemic• Insulin sensitivity and

glucose tolerance • Gut-liver axis and lipid

metabolism

Metabolic system

• Obesity• Type 2 Diabetes • Cardiovascular

diseases• NAFLD

Fight against cardiometabolic diseases

Fernandez et al. (review under revision)

Bioactive peptides

BIOACTIVE LIPIDS

CLA PPAR activator (Parodi 2016) Anti-diabetic (Ryder et al. 2001) Anti-obesogenic (Ryder et al. 2001)

Short chain fatty acids (butyric acid) (Gao et al. 2009) Increased insulin sensitivity Increased thermogenic activity

Medium-chain fatty acids Anti-diabetic (Wein et al. 2009)

Yogurt ferments

Release bioactive molecules (Fernandez et al. 2015) Conjugated linoleic acid (CLA) Bioactive peptides Exopolysaccharides

Enhanced digestion (Pei et al 2015 and Allen et al. 1982) Improved lactose tolerance Low pH of yogurt – ideal for mineral absorption

Lactic acid bacteria (Pessione et al. 2012) Antagonist behavior with other bacteria Favors healthy gut microbiota

Increase concentrations of fermentable oligosaccharides Prebiotic action on the gut microbiota

Take home messages

There is a likely favorable or neutral association between yogurt intake and adiposity indicators in children and adolescents.

There is a favorable association between yogurt consumption and T2D risk in adults – one study suggests this relationship also holds for children and adolescents.

There is a neutral association between yogurt intake and the lipid profile or blood pressure in adults – while similar results have been reported in children and adolescents, more studies are clearly needed to confirm the adult data

Pre-clinical and clinical studies are needed to demonstrate the inverse relationships between yogurt intake and the incidence of obesity and T2D found in observational studies, and to unravel the underlying mechanisms

Acknowledgments

Mélissa FernandezÉliane Picard-Deland

Noémie DanielAngelo Tremblay

Shirin PanahiMauro Fisberg

Thank you !andre.marette@criucpq.ulava

l.caQuebec city, October 2017 !