Blackwell Publishing LtdOxford, UKOBRobesity reviews1467-7881© 2006 The Authors; Journal compilation © 2006 The International Association for

the Study of Obesity200682109118

Review ArticleMilk and the metabolic syndrome M. Pfeuffer and J. Schrezenmeir

obesity reviews doi: 10.1111/j.1467-789X.2006.00265.x

Diagnostic in Obesity Comorbidities

Milk and the metabolic syndrome

M. Pfeuffer and J. Schrezenmeir

Institute for Physiology and Biochemistry of Summary

Nutrition, Federal Research Centre for Nutrition
and Food, Kiel, Germany
Received 8 December 2005; revised 7 March
2006; accepted 10 March 2006
Address for correspondence: M Pfeuffer,
Institute for Physiology and Biochemistry of
Nutrition, Federal Research Centre for Nutrition
and Food, Location Kiel, Hermann-Weigmann-
Str. 1, 24103 Kiel, Germany. E-mail:
maria.pfeuffer@bfel.de
The metabolic syndrome is a cluster of metabolic disorders, namely dyslipidaemia,
hypertension, obesity and glucose intolerance. Insulin resistance is the core phe-
nomenon. Co-occurrence is associated with increased cardiovascular disease
(CVD) risk. Observational studies found no increased CVD risk with increasing
consumption of milk and other dairy products. In several studies dairy consump-
tion was inversely associated with the occurrence of one or several facets of the
metabolic syndrome. Many dairy components may contribute to the beneficial
effects. Milk and particularly whey appeared insulinotropic when given in a single
meal, but not in longer-term intervention. Medium chain fatty acids improve
insulin sensitivity. Whey proteins, amino acids, medium chain fatty acids and in
particular calcium and other minerals may contribute to the beneficial effect of
dairy products on body weight and body fat. Peptides, calcium and other minerals
reduce blood pressure. Fermented products and probiotic bacteria decrease
absorption of cholesterol, sphingomyelin of cholesterol and fat, calcium of cho-
lesterol, bile acids and fat. Proteins, peptides and bacteria may also reduce plasma
cholesterol. Lactose, citrate, proteins and peptides improve weight control, blood
pressure and plasma lipids indirectly, by improving calcium bioavailability. Fur-
thermore, dairy consumption improves the bioavailability of folate and other
secondary plant components.

Keywords: Dairy, metabolic syndrome, milk.

obesity reviews (2006) 8, 109–118

The perspective has broadened further. Interest is now

Introduction
focused on a cluster of metabolic disorders, termed the
The longest-known predictive factor for enhanced cardio- metabolic syndrome, insulin resistance syndrome or syn-
vascular disease (CVD) risk is a high cholesterol level, drome X. The disorders belonging to the syndrome are
particularly low-density lipoprotein (LDL) cholesterol dyslipidaemia (as judged by high fasting triglyceride and
level, while high high-density lipoprotein (HDL) choles- low HDL cholesterol levels), glucose intolerance (type 2
terol levels are associated with a decreased risk. Thus, milk diabetes, impaired glucose tolerance or impaired fasting
fat soon became a suspect, as milk fat is rich in saturated glycaemia), hypertension and (central) obesity. Depending
fatty acids and high intakes of saturated fatty acids increase on the definition vascular changes evidenced by microalbu-
cholesterol levels. Yet fatty acids are also precursors of minuria are included. Hyperinsulinaemia or insulin resis-
eicosanoids, affecting inflammatory and thrombogenic pro- tance is the core phenomenon of the metabolic syndrome.
cesses, blood pressure regulation, and thus vascular func- The facets are interlinked and the co-occurrence is associ-
tion (1,2). It needs to be examined how dairy fatty acids ated with increased CVD risk (3,4). Insulin resistance is
affect these mechanisms. also associated with an increased proinflammatory and

© 2006 The Authors

Journal compilation © 2006 The International Association for the Study of Obesity. obesity reviews 8, 109–118 109
110 Milk and the metabolic syndrome M. Pfeuffer and J. Schrezenmeir
prothrombotic state (5). According to the definition of the
World Health Organization (WHO), a person afflicted with
three out of the above-mentioned disorders is considered
to suffer from the metabolic syndrome (6). As it has been
recognized as a worldwide increasing condition with seri-
ous implications for human health (3,4), there is growing
interest in a possible link between dairy food consumption
and symptoms of the metabolic syndrome.
Does milk or dairy consumption affect the risk
of cardiovascular disease?
There is no evidence from epidemiological data that milk
and dairy consumption is linked with increasing risk of
CVD. Elwood et al. (7) reviewed the available evidence up
to 2001, identifying in total 10 prospective and two case–
control studies. Their analysis showed a high degree of
consistency in the reported risk for heart disease and
stroke, all but one study suggesting a relative risk of less
than one in subjects with the highest intake of milk com-
pared with subjects with the lowest intake. A pooled esti-
mate of relative odds in these subjects, relative to the risk
in subjects with the lowest consumption, was 0.87 (95%
confidence interval [CI] 0.74–1.03) for ischaemic heart dis-
ease and 0.83 (0.77–0.90) for ischaemic stroke. In a case–
control study (8) there was a significant inverse association
with yogurt consumption. Correction for energy intake did
not change the outcome. These results relate to the con-
sumption of mainly full-fat milk, as at the time when these
studies were carried out more full-fat than low-fat milk was
on the market (7). Anyhow, no matter whether full- or low-
fat, questions on milk intake are only a rough estimate of
the whole dairy food intake. Reports from the Caerphilly
cohort indicated a trend towards a decreased risk for stroke
(9) or ischaemic heart disease (10) with increasing milk
intake. A Swedish case–control study (11) found a signifi-
cant inverse association between milk intake and the risk
of a first myocardial infarction, a Norwegian case–control
study observed a non-significant trend (12). In both studies
milk intake estimate was based on biomarkers. The find-
ings from prospective studies are in contrast to those from
several ecological studies. When the intake of various foods
was plotted country-by-country against coronary heart dis-
ease death rates (13), milk consumption showed a positive
correlation, but cheese consumption was negatively corre-
lated. Based on data from 40 countries a positive correla-
tion between coronary heart disease mortality and milk and
butterfat intake was observed in another ecological study,
but Finland and France provided important paradoxes to
the lipid hypothesis (14). Indeed, the discrepancy of low
CVD risk despite a diet high in saturated fatty acids and
cholesterol, in large part of dairy origin, has become widely
known as the ‘French paradox’. However, ecological stud-
ies provide generally the weakest evidence.
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obesity reviews
Does dairy consumption promote individual
disorders of the metabolic syndrome? Insulin
resistance, diabetes or several disorders of the
metabolic syndrome combined
Milk intake led to a significantly lower glycaemic response
compared with mixed meals (15) or lactose-equivalent
meals of white wheat bread as reference (16,17). In diabetic
subjects a lower glycaemic response to whey was not seen
after the breakfast test meal, but lateron after lunch (18).
The insulin response to milk was not different from that of
the reference meals (16,17) and the insulin response to
whey was even higher (16). This indicates that milk and
particularly whey appear insulinotropic, as judged from the
severalfold higher insulinaemic indexes than expected from
the corresponding glycaemic indexes. Addition of fer-
mented milk (yogurt) and pickled cucumber to a reference
breakfast meal significantly lowered both postprandial gly-
caemia and insulinaemia compared with the reference meal
alone (17). This suggests that fermentation or the resulting
organic acids may counteract the insulinotropic effect of
milk. A delayed gastrointestinal passage may explain the
attenuated glucose response. Release of glucose-dependent
insulinotropic polypeptide and glucagon-like peptide 1
(16,18), may be responsible for the enhanced insulin secre-
tion. A role of bioactive peptides or branched-chain amino
acids is also discussed (16).
But an insulinotropic effect is not necessarily observed in
longer-term intervention studies. When insulin-resistant
rats were fed a high-protein diet for 6 weeks, either whey
or meat protein, the whey protein concentrate reduced
plasma insulin by 40% and increased insulin sensitivity
(19). An ancillary study of the PREMIER Collaborative
Research Group found that including the Dietary
Approaches to Stop Hypertension (DASH) dietary pattern
as part of a comprehensive 6-month intervention for blood
pressure control improved insulin sensitivity beyond the
effects of a comprehensive intervention that did not include
DASH in humans (20). The DASH dietary pattern is high
in fruits, vegetables plus low-fat dairy products, while
being lower in total fat, saturated fat and cholesterol. Par-
ticipants of this study were on average 52 years of age,
69% female, 67% non-Hispanic white, obese (body mass
index [BMI] 33 kg m−2), and with an above-optimal blood
pressure (20). The beneficial effect of the DASH dietary
regimen was confirmed in another study from Iran (21).
Only a recent study in 24 boys aged 8 years found
increased fasting insulin levels and insulin resistance with
milk as compared with meat intake (22). During this 7-d
intervention, milk (around 2 L d−1) or meat provided an
additional 53-g protein per day. This resulted in an exces-
sive supply of total protein for this age. Furthermore, the
diets were not well balanced. The milk group had a higher
carbohydrate and total energy intake and gained weight
© 2006 The Authors
obesity reviews
during the intervention. It may be asked what the outcome
of a more balanced intervention would have been.
A diet high in saturated fat is linked to the pathogenesis
of insulin resistance (23,24). There seems to be a modifying
role of gender and age. No association was seen for men
as compared with women, and not in older as compared
with younger subjects (25). Dairy fat is considered a satu-
rated fat, but it contains also a large amount of oleic acid,
as well as short-chain and medium-chain fatty acids, on
average 26.5%, 3.6% and 9.7% by weight. Medium-chain
fatty acids (6:0–12:0) can improve insulin sensitivity. Dif-
ferent from long-chain fatty acids their transport across
membranes and within cells does not require binding to
fatty acid-binding proteins (26). This affects a number of
regulatory pathways. A high-fat diet decreased insulin-
stimulated glucose oxidation (27), but medium-chain fatty
acids reduced glucose oxidation less than long-chain fatty
acids in man (28). The other way round, the oxidation of
fatty acids is usually depressed when the diet is simulta-
neously high in carbohydrates. But glucose infusion
decreased only long-chain, but not medium-chain fatty acid
oxidation in muscle cells (29). Most human intervention
studies found no clear-cut effect of medium-chain fatty
acids on fasting or postprandial glucose and insulin levels
(30). In a small study in five overweight diabetics, 15 mL
d−1 of medium-chain triglycerides administered over 4
weeks attenuated the postprandial glucose response (31).
Enhanced insulin sensitivity following consumption of
medium-chain triglycerides was demonstrated in clamping
experiments (32,33). In obese subjects on a very-low-calo-
rie diet, 9.9 g d−1 of medium-chain triglycerides decreased
fasting glucose and particularly insulin levels more than the
control diet (34). The insulin resistance syndrome disturbs
metabolism of muscle, liver and adipose tissue. That
medium-chain fatty acids affect adipocyte metabolism ben-
eficially will be outlined in the chapter on obesity.
Observational studies give little indication that milk con-
sumption would increase risk of diabetes or insulin resis-
tance. When a cohort of 27 529 California Seventh-day
Adventist adults were followed for mortality because of all
causes combined, coronary heart disease, stroke, diabetes
and cancer between 1960 and 1980, there was no relation-
ship of milk or cheese consumption with any cause of death
(35). The 41 254 male participants in the Health Profes-
sionals Follow-up Study with no history of diabetes, CVD,
and cancer at baseline were followed for 12 years. It turned
out that each serving-per-day increase in total dairy intake
was associated with a 9% lower risk for type 2 diabetes
(multivariate relative risk 0.91). The corresponding relative
risk was 0.88 for low-fat dairy intake (36).
A few observational studies have examined the whole
array of the metabolic syndrome. Hallmark findings came
from the Coronary Artery Risk Development in Young
Adults (CARDIA) study (37). The study population com-
© 2006 The Authors
Journal compilation © 2006 The International Association for the Study of Obesity. obesity reviews 8, 109–118
Milk and the metabolic syndrome M. Pfeuffer and J. Schrezenmeir 111
prises 3157 adults aged 18–30 years, 45% black and 55%
white, 71% with a BMI < 25 kg m−2, who were followed
up for 10 years. Among the overweight subjects, dairy con-
sumption was inversely associated with the incidence of all
components of the metabolic syndrome. This association
was similar for blacks and whites and for men and women.
Interestingly, there was no association for persons with a
BMI < 25 kg m−2 at baseline. Dairy consumption was also
inversely associated with the risk of the metabolic syn-
drome in a cross-sectional study from Iran (38). In a study
from France, bread and dairy intake were both inversely
related to the frequency of the metabolic syndrome in men,
but not in women, while there was no association between
the intake of meat or fish and the metabolic syndrome (39).
A Swedish case–control study (11) estimated milk-fat
intake from the proportion of pentadecanoic and heptade-
canoic acid in serum phospholipids. The proportion of
these biomarkers was significantly and negatively corre-
lated to serum concentrations of plasminogen activator
inhibitor-1, tissue-type plasminogen activator, triglyceride,
insulin, specific insulin, pro-insulin and leptin, suggesting
an inverse relationship to the insulin resistance syndrome
and the risk of CVD. The validity of the biomarkers was
ascertained in a prior study by relating them with dairy
intake from 7-d dietary protocols (40). In this study, intake
of milk fat and cream was significantly inversely associated
with fasting glucose levels and an oral glucose tolerance
test (40). Only the British Women’s Heart and Health
Study, comprising 4024 women aged 60–79 years, came to
a different conclusion. Women who never drank milk had
lower insulin resistance [homeostasis model assessment
(HOMA)] scores, triglyceride levels and BMI, higher HDL
cholesterol, and suffered less frequently from diabetes than
those who drank milk. Fat content in milk played no role,
and there was no correlation with cheese consumption
(41). Non-drinkers were, however, a very small group of
111 persons, and the authors themselves did not exclude
that genetic factors associated with lactose intolerance may
be involved, as may indeed be the case (42).
Obesity
The current epidemics of diabetes and obesity seem to be
related (43). As several epidemiological and cross-sectional
studies identified calcium intake as a dietary constituent
that was inversely related to body weight and body fat, a
number of reviews addressed this topic (44–47). Several
observational studies detected inverse associations between
dairy intake and body weight, both in children (48,49) and
adults (40). Similar findings came from the CARDIA study,
in that high dairy intake protects from weight gain (37). A
high whey protein diet attenuated weight gain more than
a meat diet in rats (19). In a recent 12-week randomized,
placebo-controlled trial isocaloric substitution of yogurt
112 Milk and the metabolic syndrome M. Pfeuffer and J. Schrezenmeir
for other foods accelerated weight loss in obese subjects.
Not only was weight loss augmented, there was also a
favourable shift towards more fat loss from the abdominal
region (50). In a 6-month intervention study dairy products
exerted a substantially greater effect on both fat loss and
fat distribution relative to supplemental calcium (51).
However, another 1-year intervention study found no sig-
nificantly different weight loss between the high-dairy and
low-dairy group (52). The authors speculated that differ-
ences in baseline calcium intake and degree of adiposity at
onset may affect the response to dietary regimens (52).
There is no unequivocal consensus in the effect of dairy on
body weight, neither from controlled trials nor observa-
tional studies. As Huang & McCrory (2005) point out,
part of the discrepant findings may be due to the uncer-
tainty over whether the effect of dairy is independent of
energy intake or other eating variables (44). There may be
other yet unknown mechanisms, or there may be an addi-
tive effect of multiple factors. Dairy intake may be associ-
ated with other healthy dietary habits or lifestyles that
promote weight control.
Concerning the possible mechanisms, one hypothesis
postulates that dietary calcium plays a critical role in the
regulation of energy metabolism. Studied in cell culture and
in animal models like the agouti mouse demonstrated a key
role for intracellular Ca2+ in the regulation of adipocyte
metabolism. Increased dietary calcium reduces 1,25-
dihydroxyvitamin D activity and intracellular Ca2+ influx,
decreasing fatty acid synthesis and increasing lipolysis,
leading to decreased triglyceride stores. Furthermore,
decreased 1,25-dihydroxyvitamin D activity may up-regu-
late the expression of uncoupling protein 2 (UCP2) and this
may contribute to the increased thermogenesis observed
with high-calcium diets (45). Calcium increases also faecal
fat excretion, presumably by formation of insoluble cal-
cium-fatty acid soaps or by binding of bile acids that impair
the formation of micelles (53). In addition to dietary cal-
cium other dairy-derived bioactive compounds may con-
tribute to the augmented effect of whole dairy food intake
vs. calcium supplementation alone. Preliminary data sug-
gest that this additional activity lies in the whey fraction
(54). The whey fraction contains angiotensin-converting
enzyme (ACE) inhibitor activity. As angiotensin II regulates
in part adipocyte lipogenesis, this may be a way for whey
proteins to control this process. A role of branched-chain
amino acids is also discussed (46). Furthermore, dairy fatty
acids may help to keep weight down. Octanoic acid sup-
pressed de novo lipogenesis and triglyceride synthesis in
mouse pre-adipocytes and human adipocytes (55). Dietary
medium-chain fatty acids reduced fat mass in rodents,
through down-regulation of adipogenic genes (56).
Medium-chain fatty acids are preferentially oxidized rather
than deposited in adipose tissue triglycerides. They increase
resting metabolic rate and postprandial energy expenditure
Journal compilation © 2006 The International Association for the Study of Obesity. obesity reviews 8, 109–118
obesity reviews
(30). In clinical trials, humans fed diets containing medium-
chain fatty acids lost more body fat than those on a control
oil diet (57–59). Beta-oxidation of long-chain but not
medium-chain fatty acids was impaired in obese subjects
(60). Resting glucose and lipid oxidation and postprandial
lipid oxidation was higher in butter-fed as compared with
soybean oil-fed obese rats, and the butter diet seemed to
prevent fat accumulation in the long term. But there was
no clear beneficial effect of butter in lean animals (61).
These findings add to the idea that medium-chain fatty
acids may especially assist in the dietary management of
existing obesity. Outcome of recent trials suggest that a
moderate supply may be more beneficial than an ample
amount (30).
Hypertension
High blood pressure is defined as a systolic blood pressure
above 140 mg Hg and/or a diastolic blood pressure above
90 mg Hg. Individuals with high blood pressure are three
to four times more likely to develop coronary heart disease.
Strokes account for 17% of CVD in the United States and
hypertension is the strongest risk factor for stroke (62).
Results from the Framingham study show that even per-
sons with high-normal blood pressure have a significantly
increased risk of CVD as compared with persons with ideal
levels (63). Weight loss, sodium reduction, increased phys-
ical activity and limited alcohol intake are established rec-
ommendations that reduce blood pressure. In the CARDIA
study population the risk for 10-year cumulative incidence
of hypertension was less than 50% from the lowest cate-
gory of dairy intake (<10 times per week) to the highest
category (≥35 times per week) (37). A DASH intervention
trial showed that a diet rich in fruits, vegetables and low-
fat dairy foods reduces blood pressure significantly more
than a fruits and vegetables diet alone, in individuals with
both optimal and elevated blood pressure (64). Inclusion
of dairy products nearly doubled the effect. Participants of
this study were on average 44 years of age, 49% female,
60% African-American, overweight (BMI 28 kg m−2), and
had above-optimal blood pressure. In a further study of the
DASH Collaborative Research Group the benefit of follow-
ing the DASH dietary pattern was shown to apply through-
out the range of sodium intakes (65). In another study a
supplement of skim milk decreased blood pressure in sub-
jects with both optimal and elevated blood pressure (66).
The blood pressure-reducing effect of milk is in part due
to calcium. Numerous animal and human epidemiologic
and intervention studies have demonstrated an inverse rela-
tionship between dietary calcium and blood pressure
(62,67). Besides calcium, intake of magnesium and potas-
sium is inversely correlated with blood pressure, the appro-
priate metabolic balance of all three being important (62).
That blood pressure is beneficially influenced by the
© 2006 The Authors
obesity reviews
increasing provision of calcium, magnesium and potas-
sium, was confirmed in the Vanguard intervention study
(68). It was assumed that the action might be by virtue of
their suppressive effects on circulating vasoactive calcium-
regulating hormones. Milk contains 1200 mg calcium L−1,
and dairy foods are also a good source of potassium. Lac-
tose, citrate, proteins and peptides may improve bioavail-
ability of calcium from milk. Dairy proteins and peptides
also improve the bioavailability of other minerals and trace
elements like magnesium, manganese, zinc, selenium and
iron (69).
Peptides containing up to 10 amino acids may be
released from milk proteins through the proteolytic activity
of lactic acid bacteria, are thus found in fermented dairy
products, or may be released during the digestive process.
Many of these peptides have ACE-inhibitory (70) and
endothelin release-inhibitory activity (71). ACE is a key
enzyme in the regulation of peripheral blood pressure. The
antihypertensive potential of the peptides requires that they
reach target sites without being degraded and thus inacti-
vated by intestinal or plasma peptidases. Milk fermented
with Lactobacillus (L.) helveticus CP 790 (72), sour milk
fermented with L. helveticus and Saccharomyces cerevisiae,
as well as the two ACE-inhibitory tripeptides, Val-Pro-Pro
and Ile-Pro-Pro, isolated from the latter sour milk (73), all
showed blood pressure-reducing effect in spontaneous
hypertensive rats. Not surprising then, that small amounts
of fermented dairy products were sufficient to reduce blood
pressure in humans. Supply of just 95 mL of sour milk
instead of control milk for 8 weeks did so in elderly hyper-
tensive patients. Blood pressure remained low for another
4 weeks after end of the intervention, a phenomenon also
observed with other antihypertensive treatments (74). The
beneficial effect on blood pressure was confirmed in hyper-
tensive subjects consuming 150 mL d−1 of either L. helveti-
cus LBK-16H fermented milk or a control product for
21 weeks (75). In another placebo-controlled double-blind
34-week study (76), a daily dose of skim milk powder
equivalent to 1 L of milk from immunized cows lowered
blood pressure along with plasma cholesterol, both in nor-
motensive and hypertensive hypercholesterolaemic sub-
jects. Therefore, consumption of adequate amounts of
dairy products may decrease the risk of hypertensive heart
disease (77).
Lipid metabolism
Recent observational studies confirm that the consumption
of milk products can actually lower cholesterol levels. In
obese subjects in the CARDIA study (37) there was a trend
towards less dyslipidaemia with more frequent consump-
tion of dairy products (P = 0.07). There was an inverse
association between milk-specific fatty acids in serum cho-
lesterol esters and serum cholesterol levels and with serum
© 2006 The Authors
Journal compilation © 2006 The International Association for the Study of Obesity. obesity reviews 8, 109–118
Milk and the metabolic syndrome M. Pfeuffer and J. Schrezenmeir 113
apolipoprotein B levels in adolescents (78). Increased milk
consumption, assessed by biomarker fatty acids and 7-d
dietary records, was associated with a more favourable
LDL particle size, i.e. less small dense LDL, as well as with
lower plasma triglyceride and fasting insulin levels, and
higher HDL cholesterol (79). Small dense LDL is associated
with increased risk for CVD.
Early intervention studies showed that skim milk or
yogurt consumption might decrease plasma cholesterol lev-
els, while whole milk had neither a hypo- nor hypercholes-
terolaemic effect (80). The DASH dietary regimen, relative
to the control diet, decreased total, LDL and HDL choles-
terol, but had no effect on triglyceride levels. The effects
were more pronounced in men than in women, but did not
differ significantly by race or baseline lipid levels, except
for HDL (81). It is not clear yet what component(s) play
the part of a hypocholesterolaemic ‘milk factor’. Calcium
and magnesium from dairy products can affect lipid levels
and CVD risk beneficially. The possible hypolipidaemic
mechanism of calcium includes decreased intestinal absorp-
tion of cholesterol, of bile acids, and of fat (53). For mag-
nesium there is no obvious mechanism (82). Milk proteins
(83) or peptides (84) may also play a role. At equal fat
content, cheese consumption decreased total and LDL cho-
lesterol as compared with butter (85). When 52 hypercho-
lesterolaemic men and women received 5 g d−1 of a serum
bovine immunoglobulin for 6 weeks, total and LDL cho-
lesterol was progressively and significantly decreased by up
to 5.7% and 6.8% (86).
That fairly small amounts of fermented milk products
may decrease cholesterol levels more than non-fermented
products was corroborated in animal (80) as well as in
human studies (87,88). Certain strains of (probiotic) bac-
teria seem to be more efficient than others. In a series of
six double-blind studies in normo- or hypercholestero-
laemic subjects (87), a probiotic yogurt as compared with
a chemically fermented product decreased total cholesterol
in normo- and slightly hypercholesterolaemic subjects on
average by 4% and LDL cholesterol by 5%. Yogurt pre-
pared with additional Bifidum longum strain BL1
decreased cholesterol levels as compared with yogurt con-
taining only Streptococcus thermophilus and L. delbrueckii
ssp. Bulgaricus, and this effect was more pronounced
among moderately hypercholesterolaemic subjects (88).
One explanatory model is that some bacteria strains are
relatively resistant towards bile and show in vitro a potency
to assimilate cholesterol, which would decrease cholesterol
absorption (89). Sphingomyelin is a potentially hypocho-
lesterolaemic compound of the lipid fraction. Sphingomy-
elin is an inhibitor of pancreatic lipase-colipase and may
also decrease micellar solubilization and thus absorption
efficiency. Milk is a rich source of sphingomyelin, and
because of its high degree of saturation and long-chain fatty
acyl groups, milk sphingomyelin seems to be more effective
114 Milk and the metabolic syndrome M. Pfeuffer and J. Schrezenmeir
than egg sphingomyelin (90). As sphingomyelin is a com-
ponent of the milk fat globule membrane, it stays largely
with the buttermilk or whey fraction during processing
rather than with the butter fraction (91).
Dairy fat can be enriched with mono- and polyunsatu-
rated at the expense of saturated fatty acids by modified
feeding regimens. Consumption of a modified as compared
with a regular milk fat reduced total and LDL cholesterol
by 7.9% and 9.5% respectively, in healthy, normocholes-
terolaemic and normal-weight men (92). The effect was
more pronounced than would be predicted from the change
in the fatty acid pattern (93). Consumption of at least 250-
g milk and 150-g yogurt per day, modified as compared
with regular products, decreased LDL and increased HDL
cholesterol in another not strictly controlled intervention
study (94). As little as 300 mg d−1 of eicosapentaenoic and
docosahexaenoic acid, given together with semi-skimmed
milk for 6 weeks, decreased plasma triglyceride levels by
19% and increased HDL cholesterol by 19% as compared
with milk without these supplements (95). Plasma levels of
the ω3-fatty acids were increased by 44% and 31%
respectively. The authors’ reasoning for this pronounced
effect is that the small fat globule size and thus large surface
of milk fat improved availability and absorption efficiency
of the supplement. A similar intervention strategy signifi-
cantly decreased triglyceride, total and LDL cholesterol
levels in a larger cohort, by 24%, 9% and 13% respectively
(96). However, these studies (95,96) were not strictly con-
trolled, and more well-designed studies are needed to
examine this effect.
Plasma triglyceride levels increase after a fat meal and
return to baseline 6–12 h later. The degree of this post-
prandial response is positively correlated with CVD risk
(97). It is higher in obese and insulin-resistant than in
lean and non-insulin-resistant subjects, because of an
accumulation of triglyceride-rich remnant lipoproteins
(98,99). This postprandial triglyceride response, expressed
as area under the postprandial curve (AUC), is usually
more pronounced with saturated rather than polyunsatu-
rated fatty acids. But several times the response to milk
fat in a mixed meal was comparable to that of an oil rich
in polyunsaturated fatty acids (100–102) or was even less
(103). Different dairy products differed in their effect
with respect to degree (104) or kinetics (105) of the
response. This attenuated response is most probably due
to short-chain and medium-chain fatty acids in dairy fat
(30). In numerous studies it was lower with intake of
medium-chain rather than mono- or polyunsaturated
long-chain fatty acids (106,107). Not surprising, obese
subjects profited more from this attenuating effect than
lean subjects (108). Postprandial cholesterol response was
also reduced. The difference was mainly in what the
authors called LDL, but what might be an (atherogenic)
remnant fraction (108).
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obesity reviews
Other effects of dairy products with relevance
for the metabolic syndrome
Hyperhomocyst(e)inaemia is one of the established inde-
pendent risk factors for CVD. Elevated total homocysteine
levels (tHcy) are associated with increased risk of coro-
nary heart disease (myocardial infarction), stroke, periph-
eral vascular disease, and thrombosis. The correlation is
graded and continuous (109,110). Moderate hyperho-
mocyst(e)inaemia, generally defined as plasma tHcy con-
centrations above 15–16 µmol L−1, occurs in 20–40% of
patients with such vascular diseases (109). Dietary intake
or plasma levels of folate are inversely related to plasma
tHcy levels. Folates are found in a wide variety of foods,
especially liver, leafy vegetables, fruit, pulses and yeast.
Milk and milk products do not rank very high as a source,
but they contribute their share, particularly in countries
with high-milk intake. In a cross-sectional study of Nor-
wegian workers those with the highest intake of bread,
vegetables and skim milk had the lowest tHcy levels (111).
An inverse association between milk or yogurt intake and
tHcy levels was also found in a US population (112). Vice
versa, there was an positive association between milk
intake and folate levels in the Hordaland Homocysteine
Study (113). When participants of a DASH intervention
trial consumed a control diet, a diet rich in fruits and
vegetables or such a diet with additional low-fat dairy
products for 8 weeks, tHcy levels were progressively
decreased. The DASH regimen as compared with the con-
trol diet increased also plasma folate levels by 29% (114).
In another study the inclusion of milk in the diet enhanced
the bioavailability of food folate as assessed by the
changes in erythrocyte folate and plasma tHcy concentra-
tions (115). The whey protein fraction of milk contains a
high-affinity folate-binding protein that protects folates
from degradation and may improve their bioavailability
(116). It is a compelling speculation that milk, even the
low-fat version, improves bioavailability of several benefi-
cial ingredients from fruits and vegetables, whatever the
mechanism. This may mean that the success story of low-
fat dairy products in the DASH dietary regimen is not so
much or at least not solely due to the action of dairy foods
themselves, but by uniquely enhancing the availability of
plant compounds. That a very moderate supplement of
around 300 mg ω3-fatty acids given together with milk
had a pronounced effect on serum levels of eicosapen-
taenoic and docosahexaenoic acid (95,96), adds to this
interpretation. Low-fat milk or low-fat yogurt enriched
with plant sterols or stanols inhibited cholesterol absorp-
tion (117) and reduced LDL cholesterol by 14–16%
(118,119), i.e. to the same extent as oil-based products
(118) and almost three times more efficient than in bread
or cereals (119). Thus low-fat dairy products may be a
particularly suited matrix for functional foods.
© 2006 The Authors
obesity reviews
Conclusions
Until not so long ago, nutrition research focused on single-
nutrient interventions. Recognizing that nutrients are not
consumed individually but as combined constituents of a
varied diet, efforts in this area have shifted to the role of
the overall diet, or dietary patterns. That eating habits play
a role in the development of the metabolic syndrome has
also been concluded from the CARDIA study (120). Fast-
food frequency was directly associated with changes in
body weight and insulin resistance in both black and white
people. New food-based dietary recommendations by the
American Heart Association, with the objective of reducing
risk for CVD, promote an inclusionary approach. Obvi-
ously several risk factors for CVD can be reduced with diets
that meet the current recommended dietary guidelines. The
DASH dietary pattern, which is rich in fruits, vegetables
and low-fat dairy products, has become famous as a suc-
cessful approach to tackle several disorders of the meta-
bolic syndrome.
Observational studies found no increased CVD risk with
increasing consumption of milk and other dairy products.
In several studies dairy consumption was inversely associ-
ated with the occurrence of one or several facets of the
metabolic syndrome. Several dairy ingredients may contrib-
ute to the beneficial effects, by affecting insulin sensitivity,
weight, blood pressure and lipid levels, and possibly others.
The extent of the benefits is not clear yet. But even small
effects are relevant if additive and if exerted during a life-
time. The fact that dairy consumption may improve the
bioavailability of folate and other secondary plant compo-
nents makes it plausible that the DASH dietary pattern is
more effective than the same diet without low-fat dairy
products. Dairy intake may be associated with other pru-
dent eating habits or healthy lifestyles. Medium-chain fatty
acids may play a role, as they affect spontaneous behaviour
such that food and thus energy intake is reduced (30). It
may be that a great deal of the benefit of dairy consumption
observed in epidemiological studies derives from the fact
that dairy consumption, especially liquid dairy food, may
displace sweetened soda drinks. This may be an explana-
tion for the negative association between frequency of milk
consumption and body mass in children (49).
Conflict of interest statement
The authors declare that they have no conflict of interest.
Acknowledgement
Not applicable.
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© 2006 The Authors