Physiology & Behavior 100 (2010) 67–75

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Physiology & Behavior

j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / p h b

Dairy beverages and energy balance

Arne Astrup a, Jean-Philippe Chaput a,⁎, Jo-Anne Gilbert b, Janne K. Lorenzen a
a
Department of Human Nutrition, Faculty of Life Sciences, University of Copenhagen, Copenhagen, Denmark
b
Department of Social and Preventive Medicine, Division of Kinesiology, Faculty of Medicine, Laval University, Quebec City, Canada

a r t i c l e i n f o a b s t r a c t

Article history: High dairy intakes have been associated with lower rates of obesity in observational studies, but mechanisms
Received 1 December 2009 to explain the association are lacking. A high intake of dairy protein reduces spontaneous food intake and
Received in revised form 28 January 2010 may be one important mechanism, but more specific effects of dairy calcium seem to exist.
Accepted 30 January 2010
We have found that high versus low calcium intakes from dairy products had no effect on 24-h energy
expenditure or substrate oxidation rates, but fecal fat excretion increased ∼ 2.5-fold on the high-calcium
Keywords:
Calcium
diets. In a meta-analysis of intervention studies we found that increasing dairy calcium intake by 1200 mg/
Dairy day resulted in increased fecal fat excretion by 5.2 (1.6–8.8) g/day.
Obesity Newer research shows that humans possess taste receptors for calcium in the gastrointestinal tract and that
Fecal fat excretion signaling may be linked to appetite regulation. A new line of evidence suggests that an inadequate calcium
Appetite control intake during an energy restricted weight loss program may trigger hunger and impair compliance to the
diet.
These mechanisms may be part of the explanation for the protective effects of dairy products with regard to
obesity and metabolic syndrome.
© 2010 Elsevier Inc. All rights reserved.

1. Observational studies of the relationship between calcium/dairy
intake and body composition
In the early 1980s McCarron et al. [1] observed, in more than
10,000 participants aged 18–74 years from the NHANES I study, that
higher intakes of dietary calcium were negatively correlated with
body mass. Subsequently, Zemel et al. [2] showed a similar
relationship in adults from the NHANES III study. After controlling
for energy intake the results showed that the relative risk of being in
the highest quartile of adiposity was inversely associated with dairy
product and calcium intake. These two studies laid the groundwork
for examining the connection between calcium and/or dairy intake
and body composition in humans, and for elucidating the underlying
mechanisms.
Over the last decade a growing body of epidemiologic evidence has
emerged suggesting that calcium and/or dairy consumption is
beneficially related to body composition. Numerous observational
studies (mainly cross-sectional and retrospective cohort studies) have
examined the relationship between dairy/calcium intake and body
composition [1–60]. In the vast majority of these studies (Table 1) a
statistically significant inverse association has been reported, suggest-
ing that low calcium and/or dairy intake is associated with a greater
⁎ Corresponding author. Department of Human Nutrition, Faculty of Life Sciences,
University of Copenhagen, Rolighedsvej 30, DK-1958 Frederiksberg, Denmark. Tel.:
+45 3533 2476; fax: + 45 3533 2551.
E-mail address: jepc@life.ku.dk (J.-P. Chaput).
fat mass as well as a greater risk of weight and fat mass gain over time.
Furthermore, the inverse associations have been observed across
multiple ages and ethnicities. However, observational studies do not
prove cause-and-effect relationships and it is therefore not appropri-
ate to claim conclusively that increasing the consumption of dairy
foods results in a reduction in body weight or fat mass. These types of
studies are also challenging to interpret as they do not consider/
control for differential underreporting: overweight/obese individuals
underreport their dietary intakes to a greater extent than normal
weight people. Accordingly, one tends to observe spurious correla-
tions between “low” calcium intakes (from underreporting) and
increased body weight/fat mass. Whether increased dairy consump-
tion is simply a marker of a healthier lifestyle (including a better
overall diet and more physical activity) that is associated with less
adiposity can also not be addressed based on these observational
studies. In an attempt to avoid these well-recognized methodological
limitations researchers decided to move to randomized controlled
intervention trials (RCT).
2. Dairy calcium and body weight and fat mass: intervention trials
in adults
Intervention studies in this field of research have been conducted
using either dairy calcium (i.e., in intact dairy foods) as well as with
supplemental calcium; however, the present paper is restricted to the
studies that used dairy products in the intervention. The effect of dairy
calcium on body weight and composition has been examined in only a

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doi:10.1016/j.physbeh.2010.01.039
68 A. Astrup et al. / Physiology & Behavior 100 (2010) 67–75
Table 1
Overview of observational studies assessing the association between calcium/dairy
intake and body composition in humans.
Main finding Number References
of studies
Adults
Low calcium intake is associated 19 [1–6,9–11,17,18,21,23,28,32–36]
with greater body weight and/or
fat mass
Low dairy food intake is associated 10 [8,12,15,16,19,22,24,26,27,30]
with greater body weight and/or
fat mass
Opposite or no association 7 [7,13,14,20,25,29,31]
Children and adolescents
Low calcium intake is associated 11 [39,40,45,48,50,53,55–57,59,60]
with greater body weight and/or
fat mass
Low dairy food intake is associated 8 [37,38,44,46,47,51,52,58]
with greater body weight and/or
fat mass
Opposite or no association 5 [41–43,49,54]
few RCTs, and the majority of trials were originally designed to
examine the effect of calcium intake on bone health. Some of the first
findings to be reported were based on data from a non-RCT study in
which the antihypertensive effect of dairy calcium in obese adult
African Americans was examined [2]. Zemel and coworkers found that
increasing dietary calcium intake from ∼400 to ∼1000 mg/day for
1 year lead to a 4.9 kg reduction in body fat mass (P b 0.01) [2]. Four
subsequent RCTs were conducted by this research group to assess the
effect of dairy calcium intake secondary to energy restriction
(−500 kcal/day) on body fat mass (see Table 2) [61–63,67]. In three
of these studies, a substantial effect on body fat mass and body weight
loss was found: in subjects assigned to a diet with a high content of
dairy calcium (1100–1300 mg/day) body fat and body weight loss
was augmented by 33–56% and 33–85% respectively, compared to
subjects assigned to a similar diet with a low calcium content (400–
500 mg/day) [61–63]. Similar results have been found by others [64].
It has been suggested that dairy calcium has a more pronounced effect
on body fat than supplementary calcium, which may be due to other
bioactive components of the dairy products affecting body fat mass
(protein, peptides, etc.) [62,65,66]. In contrast, Thompson and
coworkers found no effect of a high-calcium intake on adiposity
(Table 2) [67]. There are several possible explanations for these
conflicting findings. Firstly, studies of this nature cannot be blinded, so
dietician bias could have affected the results of the first three studies
by Zemel et al., resulting in an overestimation of the true effect. In the
study by Thompson et al., although non-significant, the authors
reported a greater reduction of body fat mass and body weight in the
high-calcium group compared to the low calcium group (1.8 kg).
Secondly, although the differences in calcium intake between groups
were similar in all four studies, the daily calcium intake in the control
group in the first three studies was slightly lower than in the last study
(400–500 mg/day vs. 800 mg/day). As the subjects in the control
group in the Thompson et al. study had a body fat mass loss similar to
that observed in the high-calcium group in one of the previous studies
(7.5 vs. 7.2 kg body fat mass) [61], the authors proposed the existence
of a threshold value of about 600–800 mg/d above which increased
calcium intake has no further beneficial effect on body weight and
body fat mass, and similar suggestions have been made by others
[9,21,65]. Subsequently, three other RCTs found that increased dairy
calcium during energy restriction had no effect on loss of body fat or
body weight (Table 2) [68–70].
Only four RCTs have reported the effect of dairy calcium on change
in body fat mass in adults during energy balance (Table 2) [61,71–73].
One of these studies found that increased dairy calcium intake
produced body fat loss [61], whereas the three other studies found no
effect [71–73]. Zemel et al. [61] found that subjects allocated to a high-
calcium diet (1200 mg/day) lost 2.16 kg body fat (P b 0.01) over
24 weeks, whereas no significant change was seen in subjects
allocated to a low calcium diet (500 mg/day). In contrast, Gunther
et al. [73] reported that an increase in dairy calcium intake (from low-
fat milk) did not affect change in body fat mass over 1 year. Although
they aimed at a difference in calcium intake of ∼ 600 mg/day between
the control group and the high dairy group, they only obtained a
difference of 390 mg/day. In the studies by Zemel et al. the difference
between the groups was ∼ 800 mg/day. This may, at least in part,
explain the inconsistency between the results from the study by
Gunther et al. [73] and those from the study by Zemel et al. [61].
Furthermore, the study by Gunther et al. only included normal weight
women, whereas the subjects included in the study by Zemel et al.
were obese. Six months after completion of the intervention by
Gunther et al. a follow-up study in 51 of the subjects was performed.
Here it was found that mean calcium intake over the 18 months
predicted a small reduction in body fat mass [74]. The authors
estimated that a normal weight woman who increased her daily
calcium intake for 18 months from 500 mg/day to 1200 mg/day could
expect to accumulate ∼ 1.9 kg less body fat mass [74].
3. Dairy calcium and body weight and fat mass: intervention trials
in children and adolescents
Six RCTs have evaluated the effect of dairy calcium on body fat in
children/adolescents (Table 3) [75–80]. In a study in young children
(n = 50) it was found that increasing dairy calcium intake by about
600 mg/day prevented body fat gain over 6 months in comparison to a
control group consuming their habitual diet (control group gained
∼1.5 kg body fat mass, P b 0.001) (Table 3) [76]. In the five other
studies no effect was found, i.e. dairy calcium did not affect body fat
gain, but in three of the studies the intervention group increased their
energy intake without gaining weight [75,78,79]. This difference in
energy intake was not accounted for, and it therefore seems likely that
an effect would have been found if energy intake had been the same in
the two groups. This highlights a very important issue, i.e. that
increasing intake of dairy products in order to increase the intake of
dietary calcium may lead to an increased energy intake, which would
counteract the potential effect of calcium on body fat mass and body
weight. The studies in children and adolescents were all small, and
were not designed to address the effect on body fat mass.
4. Conclusion on intervention studies
Though inconclusive, data from RCTs examining the effect of dairy
calcium on body fat mass and body weight in adults suggest that dairy
calcium may both enhance loss of body fat during energy restriction
and limit weight gain. However, the majority of these studies that
found an effect of dairy calcium on body composition were conducted
in one lab (Zemel et al.) and had small sample sizes. Data from studies
in children and adolescents are less clear, and may be confounded by
differences in energy intake between the groups. However, it is
important to emphasize that no clear conclusions on the effect of
calcium per se can be drawn from these studies [81–83]. Other
substances in dairy products (e.g. dairy proteins) might exert
beneficial effects on satiety and energy balance.
5. Potential mechanisms for an effect of dairy calcium on
body composition
Although the intervention studies are not conclusive, it is important
to consider possible mechanisms by which calcium could have an effect
on body weight or composition. Zemel et al. [2] first provided—using
animal models of obesity—the first plausible mechanism to explain
the findings of some previous epidemiological studies. This “calcium
Table 2
Intervention studies examining the effect of dairy calcium on obesity-related variables in adults.

Ref Country Population Design Intervention Key findings

Control group Calcium group Calcium group

Zemel et al. USA 32 obese women and RCT, parallel, 24 weeks, energy Controlled diet: Controlled diet: 1200– Controlled diet: 1200– The dairy calcium group and the supplementary calcium group lost
[61] men, low habitual restricted diet (− 500 kcal/ 400–500 mg 1300 mg calcium/day mainly 1300 mg calcium/day significantly more body fat mass (7.16 ± 4.0 and 5.61 ± 3.3 vs. 4.81 ±
calcium intake (500– day) calcium/day from dairy products (n = 11) mainly from calcium 3.9 kg, p b 0.01) and body weight (11.07 ± 5.4 and 8.58 ± 5.3 vs. 6.60 ±
600 mg/day) (n = 10) carbonate (n = 11) 8.2 kg, p b 0.01) than the control group. Loss of body fat mass and body
weight was significantly higher in the dairy calcium group than in the
supplementary calcium group (p b 0.01 for both).
Zemel et al. USA 34 obese African- RCT, parallel, 2 phases Controlled diet: Controlled diet: 1200 mg Phase 1: The calcium group lost 2.16 kg body fat (p b 0.01). There was
[62] American women and 500 mg calcium/ calcium/day mainly from no significant change in the control group. No significant change in
men, low habitual day (n = 17/12 in dairy products (n = 17/17 in body weight in either group.
calcium intake (b 600 mg/ Phase 1: 24 week weight phase 1/2) phase 1/2) Phase 2: The calcium group lost significantly more body fat (9.08 vs.
day) maintaining 3.97 kg, p b 0.01) and body weight (11.02 vs.5.95 kg, p b 0.01) than
Phase 2: 24 week weight the control group.

A. Astrup et al. / Physiology & Behavior 100 (2010) 67–75

reducing (− 500 kcal/day)
Zemel et al. USA 34 obese women and RCT, parallel, 12 week energyControlled diet: Controlled diet: 1100 mg The calcium group lost significantly more body fat mass (4.43 ± 2.0
2005 [63] men, low habitual restricted diet (−500 kcal/day)
400–500 mg calcium/day mainly from vs. 2.75 ± 2.9 kg, p b 0.005) and body weight (6.63 ± 2.5 vs. 4.99 ±
calcium intake (500– calcium/day yoghurt (n = 18) 2.0 kg, p b 0.01) than the control group.
600 mg/day) (n = 16)
Summerbell UK 20 male & female, Parallel, 16 weeks, very low Conventional diet Only milk and yoghurt The calcium group lost more body weight than the control group
et al. [64] BMIN27 kg/m2, N 17 years. energy diets ∼3.4 MJ composed of a (n = 11) (11.2 ± 5.2 vs. 2.6 ± 4.1 kg, significance not stated).
variety of normal
foods (n = 9)
Thompsen USA 48 obese women and men RCT, parallel, 48 week energy Controlled diet: Controlled diet: 1400 mg There was no significant difference in loss of body fat mass or body
et al. [67] restricted diet (−500 kcal/day) 800 mg calcium/ calcium/day mainly from weight between the two groups. There was a non-significant trend
day (n = 26) dairy products (n = 22) towards an increased loss of body fat (1.81 kg) and body weight
(1.4 kg) in the calcium group.
Harvey- USA 54, men and women, BMI RCT, 12, months, energy Controlled diet: Controlled diet: 1200– There was no significant difference in loss of body fat mass or body
Berino 25–35 kg/m2, low restricted diet (−500 kcal/day) 500 mg calcium/ 1400 mg calcium/day mainly weight between the two groups. There was a non-significant trend
et al. [68] habitual calcium intake day (n = 29) from dairy products (n = 25) towards an increased loss of body fat (∼1 kg) and body weight
(b 700 mg/day) (∼1 kg) in the calcium group.
Bowen et al. Australia 50 obese women and men RCT, parallel, 12 weeks energy Controlled diet: Controlled diet : 2400 mg There was no significant difference in loss of body fat mass or body
[69] restriction (5.5 MJ/d) and 500 mg calcium/ calcium/day mainly from weight between the two groups.
4 weeks energy balance, high day (n = 25) dairy products (n = 25)
protein diet (34 E%)
Wagner USA 41 obese premenopausal RCT, 12 weeks, energy Controlled diet: Controlled diet: 1550 mg No significant difference in change in body weight between the
et al. [70] women. Habitual calcium restriction (−500 kcal/day) 750 mg calcium/ calcium/day mainly from groups. The calcium group lost significantly less body fat mass
intake ∼750 mg/day and exercise (3 times/week) day (n = 13) dairy products (n = 7) (∼2 kg; p b 0.05) than the control group.
Gunther USA 135 young women, RCT, 1 year, energy balance Habitual diet 1000–1100 mg calcium/day 1300–1400 mg calcium/ There was no significant difference in change in body fat mass or
et al. [73] normal weight, low (b 800 mg mainly from dairy products day mainly from dairy body weight between the groups.
habitual calcium intake calcium/day) (n = 45) products (n = 48)
(b 800 mg/day) (n = 42)
Barr et al. USA 204 healthy men and RCT, 12 weeks, no energy Habitual diet Habitual diet plus 3 servings of The calcium group gained 0.6 kg more than the control group
[72] women 55 to 85 years, restriction low-fat milk (600 ml/day). No (p b 0.05). This was less than predicted from the added amount of
2
BMI 16–36 kg/m , low instructions to adjust for the milk.
habitual dairy intake added energy
Baran et al. USA 37 premenopausal RCT, 3 years, no energy Habitual diet Habitual diet plus 500– The calcium group gained 4.2 kg and the control group 3.4 kg
[71] women, 30–42 years. restriction (n = 17) 600 mg calcium/day from (significance not stated). The calcium group had a significant
Habitual calcium intake dairy products (n = 20) increase in energy intake of ∼470 cal/day (p b 0.01). No significant
∼900 mg/day change in the control group.

69
70 A. Astrup et al. / Physiology & Behavior 100 (2010) 67–75

Table 3
Intervention studies examining the effect of dairy calcium on obesity-related variables in children and adolescents.

Reference Country Population Design Intervention Key findings

Control Calcium

Chan & USA 50 children, 2.5– RCT, 6 months Habitual diet (n = 25) Habitual diet plus dairy Control group gained 1.5 kg body fat mass (9.1±
McNaught [76] 8.8 years, low habitual products (1200 mg 3.8 to 10.6± 4.7, p b 0.001). No significant change
calcium intake calcium/day) (n = 25) in the high dairy group.
(b 800 mg/day)
Cadogan et al. UK 80 healthy white RCT, parallel, Habitual diet (703 ± Habitual diet plus 568 ml No significant difference in body fat or body
[75] girls, mean age 18 months 205 mg calcium/day) (one pint) whole or low-fat weight gain between the groups. Trend towards
12.2 ± 0.3 years (n = 37) milk (1125 ± 294 mg an increase in energy intake in the high dairy
calcium/day) (n = 43) group (p = 0.065) but not the control group. At
the end of the study the high dairy group
consumed ∼1000 kJ/day more than the control
group.
Merrilees et al. New 91 girls, 15–16 years RCT, 2 years Habitual diet (683.9 ± Habitual diet plus dairy No significant difference in body fat or body
[79] Zealand 316 mg calcium/day) products (1155 ± 351 mg weight gain between the groups. High dairy
calcium/ day). group had a non-significant increase in energy
intake (∼ 600 kJ/day) which was not seen in the
control group.
Lappe et al. [78] USA 59 girls, 9 years RCT, parallel, Habitual diet (961 ±Habitual diet plus calcium- No significant difference in body fat or body
24 months 268 mg calcium/day) rich foods including weight gain between the groups. High dairy
(n = 32) fortified products (1656 ± group consumed ∼ 600 kJ per day more than
191 mg calcium/day) control group (ns).
(n = 27)
Chan et al. [77] USA 46 girls, 11 years RCT, parallel, Habitual diet (728 ± Habitual diet plus dairy No significant difference in body fat or body
12 months 66 mg calcium/day) products (1437 ± 78 mg weight gain between the groups.
(n = 24) calcium/day) (n = 22)
Volek et al. [80] USA 28 boys, 13–17 years RCT, parallel, Habitual diet plus Habitual diet plus low-fat No significant difference in change in body fat
12 weeks, both juice (708 ml/day, milk (1%) (708 ml/day, or body weight between the groups. No
groups exercised 979 ± 286 mg 1723 ± 274 mg calcium/ significant difference in energy intake between
1 h 3 days/week calcium/day) (n = 14) day) (n = 14) the groups.

ns: non-significant; RCT: randomized controlled trials.

hypothesis” stipulates that dietary calcium, via its influence on plasma
1,25-dihydroxyvitamin D3 (calcitriol) concentrations, regulates the
concentrations of calcium within the adipocytes and, thereby, influ-
ences fat metabolism in the adipocytes. According to this theory, a low
dietary calcium intake inhibits lipolysis, stimulates de novo lipogenesis,
and decreases fat oxidation. The hypothesis has prompted the
realization of numerous studies; however, this view was refuted by
other research groups.
Dairy foods might also modulate body weight regulation by
calcium-independent mechanisms. This could be, for example, the
case of milk and its bioactive compounds. It has been shown that dairy
proteins suppress short-term food intake, increase satiety, and
stimulate food intake regulatory mechanisms known to signal
satiation and satiety [65]. Milk proteins are also insulinotropic and
peptides derived from them affect the renin–angiotensin system,
which may partly contribute to explain the association between dairy
consumption and reduced prevalence of the metabolic syndrome
through mechanisms other than their effect on satiety [65]. Thus, milk
proteins may be an important factor explaining the association
between dairy consumption and healthier body weights. Whey and
casein are present in cow milk in proportions of approximately 20%
and 80%, respectively. Besides, two other potential explanations for
the association between dairy food intake and body fat that have
received considerable attention recently are the effect of dietary
calcium on fecal fat excretion as well as the calcium appetite concept.
5.1. Effect of dietary calcium on fecal fat excretion
Animal studies almost unambiguously show that increased dietary
calcium intake produces increases in fecal fat excretion [84–94]. The
studies indicate that a 2–3-fold increase in dietary calcium intake
produces a decrease in fat digestibility of 3–10% [85,87,89,90]. The
mechanisms by which dietary calcium may produce an increased fecal
excretion of fat is formation of insoluble calcium-fatty acid soaps and
formation of hydrophobic aggregations with phosphorus, bile acids,
fatty acids and other hydrophobic components [95–98]. An increased
excretion of bile acids in response to an increase in dietary calcium
intake has also been reported in several animal studies [87,89–91]. It
is difficult to provide a quantitative estimate of the effect size, but it
seems to be of the order of a 2–3-fold increase in dietary calcium
intake producing a 1.5–2.0-fold increase in total bile acid excretion
[87,89,90]. In two of these studies an inverse relation between bile
acid excretion and fat digestibility was reported [87,89]. Xu et al. [89]
observed that an increase in fecal bile acid excretion by 1 µmol/day
was associated with a decrease in fat digestibility of 0.066 percentage
units in rats, independent of calcium and protein intake. In agreement
with this, Yungklang et al. [87] found that bile acid excretion could
explain 71% of the variation in fat digestibility in veal calves.
5.2. The overall effect of calcium on fecal fat excretion in humans
In a number of human intervention studies we and others have
demonstrated that an increase in dietary calcium intake produces
increased fecal fat and energy excretion which can contribute to a
negative energy balance [99–107]. Not all studies have found
significant effects, but many of the studies have included only a
small number of experimental subjects [100,108–110]. We therefore
conducted a meta-analysis including all the available RCTs [111]. We
found that increased calcium intake (from supplements or dairy
products) resulted in an increased excretion of fecal fat or fatty acids
compared to control groups, with a standardized mean difference
(SMD) of 0.99 (95% CI: 0.63 to 1.34; z = 5.44, P b 0.0001) (Fig. 1A and
B). Assuming a mean fat excretion in the population of 5.4 ± 2.0 g/day
[109], the increase in calcium intake corresponded to an increase in
excretion of fecal fat of 2.0 g/d (95% CI: 1.3 to 2.7 g/day), i.e. an
increase of 37%. This corresponds to an increase in energy excretion of
76 kJ/day. Assuming that an increased fat excretion of 14.64 MJ/year
(3500 kcal) produces a weight loss of 0.45 kg/year, and that subjects
maintain the same energy intake and no long-term adaptation takes
place, this corresponds to a weight change of −0.9 kg/year. However,
the heterogeneity of these studies was relatively high (I2 = 49.5%)
(Fig. 1) and there was considerable inconsistency in the results. This
 A. Astrup et al. / Physiology & Behavior 100 (2010) 67–75 71

Fig. 1. A. Effects of calcium supplementation (from supplements or dairy products) on fecal fat excretion. Every square represents the individual study's standardized mean
difference (SMD) with 95% CI indicated by horizontal lines. Square sizes are directly proportional to the precision of the estimate. B. Amount of fecal fat excreted among the
homogeneous studies following extra calcium from dairy products in healthy subjects. Every square represents the individual study's mean difference with 95% CI indicated by
horizontal lines. Square sizes are directly proportional to the precision of the estimate. Figure reproduced with permission from Christensen et al. [111].

suggests that the outcome of this meta-analysis was confounded by
differences in study design, study population, intervention (tablets or
fortified food, dose of calcium and calcium salt), and measures of fat
excretion (days of collection, measuring of total fat or fatty acids and
method used for analyzing fat). When the studies were divided into
studies on supplementary calcium and studies using dairy calcium a
large heterogeneity was found among the supplementary studies
(I2 = 58.5%), whereas the studies using dairy calcium showed
homogeneity (I2 = 0%). A meta-analysis based on the studies using
dairy calcium showed that a weighted-average increase in dairy
72 A. Astrup et al. / Physiology & Behavior 100 (2010) 67–75

calcium of 1241 mg/day produced an increase in fecal fat excretion of

5.2 g/day, though based on a relatively small sample (n = 29
participants). This corresponds to a change in weight of −2.2 kg/year.

5.3. Potential influence of calcium on appetite control in the context of

energy restriction

Intervention studies have shown different conclusions about the

effect of calcium/dairy supplementation on body weight loss. To
explain these conflicting findings [112], it has recently been proposed
that certain conditions have to be met to detect the beneficial impact
of dairy/calcium consumption on weight loss [113]. In fact, interven-
tion studies that submitted overweight or obese participants who
consumed less than 600 mg calcium a day to an energy restricted
program (− 500 kcal/day) have shown that the dairy/calcium
supplementation induces a greater weight loss than what is observed
in the placebo group [62,114]. The existence of the calcium threshold
effect has been claimed to be a key factor [115,116]. Some authors
have also raised the point that energy restricted diet increases the
risk of calcium deficiency and therefore may lead to hunger, non-
compliance, and subsequently decrease the chances of achieving weight
Fig. 2. Impact of calcium + vitamin D supplementation combined to an energy
loss [65].
restricted program on changes in spontaneous lipid intake during a buffet-type meal
Recently, Tordoff [117] has reviewed the evidence of sensory and test in low (b 800 mg calcium/day at baseline) and very low (b 600 mg calcium/day at
behavioral regulation of body calcium and has proposed the existence baseline) calcium consumer (CC) women. Adapted from Major et al. [114].
of a taste for and appetite for calcium. The calcium appetite concept he
proposes suggests that dietary calcium deficiency leads to an increased
motivation to seek out or choose calcium-rich food. Different research portions of dairy products in the daily diet resulted in significantly
groups have verified the increase in spontaneous calcium consump- increased energy intake in comparison to the addition of a single dairy
tion after calcium deprivation in animals [118,119], and some have product each day, independently of the baseline group. Moreover, the
also shown that macronutrient preferences are influenced as well increased dairy product intake did not elicit any changes in hunger or
[120]. In addition, Tordoff's research group has recently identified fullness sensations that would suggest a compensatory appetitive
some genes involved in the recognition of the taste of calcium [121]. response for the additional calories. Results of the latter short-term
This group has also raised the possibility that humans can detect such a study cast doubt on a role for increased dairy product consumption in
calcium flavor [122]. Additional work is however needed to reach a body weight regulation during energy balance (as opposed to energy
complete understanding of the control of calcium consumption and its restriction).
influence on appetite and energy consumption. Some authors propose mechanisms that support the calcium
In addition to the enticing references to the past and anecdotal appetite concept and its influence on food intake. For example, Tordoff
observations of the clinical literature Tordoff has reviewed [117], the relies on the identification of some genes that play a role in taste
results from a recent randomized, double-blind, placebo-controlled recognition [121]. Others have found that overweight women with
trial, conducted on women consuming low levels of calcium (b800 mg/ low calcium intake who are instructed to consume 3–5 portions of
day), support the existence of a human calcium appetite [114]. Although dairy products daily show an increase in fasting leptin levels after a 6-
in the study group as a whole (n = 63) there was no effect of the month intervention [124]. Considering the role of leptin in appetite
intervention on loss of fat mass, the authors discovered some interesting control [125], these recent observations represent a starting point for
findings among the very low calcium consumers (b600 mg Ca/day, future investigations designed to improve our understanding of the
n = 7 for calcium+ D and n =6 for placebo) of the sample. Indeed, a calcium appetite concept and its impact on appetite control.
calcium + vitamin D supplementation induced a significantly decreased
spontaneous lipid intake at the buffet-type lunch after the 15-week
energy restricted program (Fig. 2). Unlike the calcium supplemented
group, the placebo group showed a slight but not significant increase in
lipid intake and did not experience body weight changes. The authors
proposed that the results tie-up with the calcium-specific appetite
concept by suggesting that an adequate calcium intake may reverse the
appetite driven-behavior associated with dietary calcium deficiency. In
addition, the same research group has recently conducted a similar
randomized, placebo-controlled trial with low calcium consuming
women and has found that a milk supplementation providing
1000 mg Ca/day attenuates the diet-induced increase in appetite as
observed in the placebo group (unpublished results). Taken together,
the idea that higher calcium intake may lead to better appetite control
during a weight loss program is a hypothesis that is worth exploring in
the future.
In counterpart, the influence of dairy product consumption on food
intake and appetite sensations was explored in the context of energy
Fig. 3. Trend in sweetened beverage and milk consumption among Americans between
balance in a recent crossover study with individuals who were habit- 1977 and 2001. Sweetened beverage combines soft drinks and fruit drinks. The sample
ually low (b1 serving/day) or high (N3 servings/day) dairy consumers consisted of 73,345 individuals aged ≥ 2 years. Figure adapted from Nielsen and Popkin
[123]. The authors observed that the addition during 7 days of three [126].
 A. Astrup et al. / Physiology & Behavior 100 (2010) 67–75
6. Conclusion
Data from observational studies are indicating that dairy beverage
consumption is healthy and inversely associated with body weight
and body fat in humans. However, intervention studies examining the
effect of dairy calcium on body fat mass and body weight are not
conclusive. Possible mechanisms by which dairy beverages may affect
energy balance include the well-known satiating effect of dairy
proteins, the increased fecal fat excretion as well as the calcium
appetite concept. Future research will be needed in this area before
recommendations can be made regarding the potential of dairy
products in preventing overweight and obesity. This issue is relevant
in a context where people drink less milk and more sweetened
beverages nowadays compared to 30 years ago (Fig. 3).
Conflicts of interest
Arne Astrup is a member of the scientific advisory board for Global
Dairy Platform, Chicago, USA, member of Cadbury's Nutrition
Advisory Panel, and recipient of research funding from the Danish
Dairy Foundation and Arla Foods. He has also received speaker's
honoraria from a number of dairy companies. Jo-Anne Gilbert receives
a PhD scholarship from the Danone Institute of Canada.
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