Eur J Nutr
DOI 10.1007/s00394-016-1341-7
REVIEW
A systematic review of the effect of yogurt consumption
on chronic diseases risk markers in adults
Audrée‑Anne Dumas1,2 · Annie Lapointe1 · Marilyn Dugrenier1 ·
Véronique Provencher1,2 · Benoît Lamarche1,2 · Sophie Desroches1,2 
Received: 26 May 2016 / Accepted: 23 October 2016
© Springer-Verlag Berlin Heidelberg 2016
Abstract  reduced total cholesterol concentrations, ratio of total cho-
Purpose  We reviewed randomised controlled trials (RCTs)
that have assessed the effects of yogurt containing Lactoba‑
cillus bulgaricus and Streptococcus thermophilus (LBST)
on metabolic risk markers of chronic diseases in adults.
Methods We performed a systematic search in July 2016
in the scientific databases PubMed, EMBASE and The
Cochrane Library. Included studies were RCTs that
assessed the impact of consuming yogurt containing LBST
as a treatment, and that evaluated at least one metabolic
risk marker for chronic diseases compared with a control
diet or a diet supplemented in another food/ingredient in
healthy or chronically ill adults.
Results Seven RCTs involving 278 participants were
included in the review. Studies were conducted in the USA,
France, Spain, Iran and Canada. Five studies were under-
taken in healthy adults, and two were conducted among
lactose malabsorbers. All studies investigated changes in
blood lipids and glucose homoeostasis, with different doses
of yogurt, durations of the supplementation and risks mark-
ers assessed. Consumption of LBST yogurt significantly
Electronic supplementary material  The online version of this
article (doi:10.1007/s00394-016-1341-7) contains supplementary
material, which is available to authorized users.
* Sophie Desroches
sophie.desroches@fsaa.ulaval.ca
1
Institute of Nutrition and Functional Foods, Laval University,
Pavillon des services, 2440 Hochelaga Boulevard, Quebec
City, QC G1V 0A6, Canada
2 cancers and diabetes, share several underlying metabolic
School of Nutrition, Faculty of Agriculture and Food
Sciences, Laval University, Pavillon Paul‑Comtois, 2425
Agriculture Street, Quebec City, QC G1V 0A6, Canada
lesterol to HDL-C and plasma glucose compared to a con-
trol yogurt-free diet or diet supplemented in another food/
ingredient in two out of the seven studies. The majority of
included RCTs presented high to unclear methodological
risks of bias, which raises questions about the validity of
their findings.
Conclusions  Data from this systematic review indicate that
the consumption of LBST yogurt shows either favourable
or neutral effects on metabolic risk markers when com-
pared with a control treatment in controlled research set-
tings. RCTs investigating the effect of LBST yogurt con-
sumption on metabolic risk markers of chronic diseases are
scarce and presented considerable variation in methodolo-
gies making comparison between studies difficult. Further
large-scale, well-designed studies assessing the impact
of LBST yogurt, in particular in comparison with a con-
trol yogurt-free diet, are warranted to effectively evaluate
the effect of yogurt consumption per se on risk markers of
chronic diseases.
Keywords  Yogurt · Dairy products · Chronic diseases risk
markers · Systematic review
Introduction
The important rise in the prevalence of noncommunica-
ble chronic diseases has become a major target for global
health promotion, as noncommunicable chronic diseases
deaths are projected to reach 52 million by 2030 [1]. The
main chronic diseases, including cardiovascular diseases,
and physiological risk factors such as abnormal lipid pro-
files, raised glucose levels [1] and elevated plasma-free
13

fatty acids [2]. There is strong evidence supporting the
important role played by lipid abnormalities, including ele-
vated total cholesterol, low-density lipoprotein cholesterol
(LDL-C) levels, ratio of total cholesterol to high-density
lipoprotein cholesterol (HDL-C) and triglycerides, as well
as low HDL-C plasmatic concentrations, in the aetiology
of atherosclerosis and subsequent cardiovascular risk [3].
The reduction in plasma LDL-C concentrations is one of
the main therapeutic targets for the prevention of cardio-
vascular diseases [4–6]. Moreover, high serum cholesterol,
low HDL-C cholesterol concentrations, hyperglycaemia
and insulin resistance are among the metabolic risk fac-
tors included in the definition of the metabolic syndrome
[7], a specific subset of cardiometabolic risks that have
been associated with an increase in relative risk of cardio-
vascular diseases and development of type 2 diabetes [8,
9]. Short-chain fatty acids are other targets of interest in
regards to obesity and cardiometabolic disorder prevention
[10]. Short-chain fatty acids are organic fatty acids with
one to six carbon atoms produced in the distal gut by bac-
terial fermentation of complex carbohydrates unabsorbed
in the upper gastrointestinal tract and entering the colon.
They have been shown to be central to the physiology and
metabolism of the colon [11] and have been associated with
improved beneficial effects on the host energy metabolism
and inflammatory responses [12].
The common causes of these multifactorial noncom-
municable chronic diseases are modifiable behavioural risk
factors including, physical inactivity, tobacco and alco-
hol use as well as an unhealthy diet and excessive energy
intake [1]. Consumption of a healthy diet is recognised
as the cornerstone in the prevention of many noncommu-
nicable chronic diseases and is inherent to lifestyle inter-
ventions aiming to improve lipid profile [4, 13], glucose
homoeostasis [14, 15] and blood pressure [16], as well as
controlling and reducing obesity [17, 18]. A growing body
of epidemiological evidence supports the beneficial effects
of dairy products consumption on health outcomes, includ-
ing reduced risks of type 2 diabetes [19–22]. In particular,
the benefits of yogurt on cardiometabolic risk have recently
drawn a lot of attention among scientific experts [23–25].
Being part of the human diet for thousands of years [26],
yogurt is defined by the Codex standard as the product of
fermentation of the starter symbiotic cultures Lactobacil‑
lus delbrueckii subspecies bulgaricus and Streptococcus
thermophilus (LBST) [27]. Yogurt provides valuable nutri-
ents, namely high-quality proteins, calcium and potassium
[28], and is considered an integral component of a healthy
well-balanced diet [29, 30]. Yogurt consumption has been
associated with an overall better diet quality [31–34], and
observational studies have reported positive effects of
yogurt consumption on health outcomes, such as a lower
incidence of type 2 diabetes [19–22]. The epidemiologic
13
Eur J Nutr
nature of these evidences, however, prevents clear conclu-
sions about the causal relationship between yogurt con-
sumption and clinical outcomes, as well as the identifica-
tion of their underlying physiological mechanisms. Thus,
the investigation of the impact of yogurt on health, through
underlying metabolic risk markers, needs to be examined
by rigorous randomised controlled trials (RCTs). The pur-
pose of the present systematic review is to summarise the
results from RCTs that have assessed the impact of conven-
tional yogurt containing LBST on metabolic risk markers
of chronic diseases in adults.
Methods
The present review is reported according to the Preferred
Reporting Items for Systematic Reviews and Meta-Anal-
yses statement (PRISMA) [35]. In that regard, a protocol
was developed a priori when funding was sought and was
used as a guide to carry out the review. Ethical approval
was not required as no human subjects were involved.
Study eligibility criteria
The review included RCTs that assessed the impact of con-
ventional yogurt containing LBST consumption as a treat-
ment and evaluated at least one metabolic risk marker for
chronic diseases defined by the World Health Organization
(i.e. cardiovascular diseases, cancers, chronic respiratory
diseases and diabetes) [1] compared with a control normal
yogurt-free diet or a diet supplemented with another food/
ingredient, in healthy or chronically ill adults of 18 years
and older (Table 1). Prior to the beginning of the study, we
determined that studies including children or teenagers, as
well as studies in which LBST yogurt was used as a con-
trol, would be excluded from the review.
Search strategy
An extensive systematic search was conducted in Pub-
Med, EMBASE and The Cochrane Library, using 13 July
2016, as the cut-off date. We present the details of the dif-
ferent search strategies, which account for specificities of
all scientific databases in Supplementary material 1. No
restriction was set for language or year of publication. All
databases were searched from their start date. References
cited in all included studies were additionally reviewed and
obtained for assessment.
Data collection
Three review authors (A.L., M.D. and A-A.D.) indepen-
dently assessed the eligibility of papers identified by the
Eur J Nutr

Table 1  Criteria for considering studies for this review

Eligibility criteria

Types of studies Randomised controlled trials with no time or language restriction

Types of participants
Types of interventions
Types of comparators
Types of outcome measuresa
Examples of metabolic risk markers
Healthy or chronically ill adults aged 18 years and over
Studies assessing the impact of consuming yogurt containing L. bulgaricus and S. thermophilus as a
treatment
A control normal yogurt-free diet or a diet supplemented with another food/ingredient
All metabolic risk marker for the main chronic diseases:
• Cardiovascular diseases (e.g. heart disease, stroke);
• Cancers;
• Chronic respiratory diseases (e.g. chronic obstructive pulmonary disease, asthma);
• Diabetes
Raised blood pressure
Raised blood glucose
Abnormal blood lipids (e.g. increased low-density lipoprotein (LDL) cholesterol concentrations, high
triglycerides)
Subclinical inflammation (e.g. elevated plasma concentrations of C-reactive protein and of proinflamma-
tory cytokines TNF-α and IL-6)
Overweight and obesity

TNF-α, tumour necrosis factor alpha; IL-6, Interleukin 6

a
  The categorisation of main chronic diseases and their risk markers is based on the definition of the World Health Organization [1]

search strategy. First, all titles and abstracts were screened
according to pre-established inclusion criteria (Table 1).
Then, full-text copies of papers judged potentially relevant
to the review were retrieved. Disagreements were resolved
through discussion between three review authors (A.L.,
M.D. and A-A.D.) and with a fourth review author (S.D.)
when consensus was not reached. When papers contained
insufficient information to make a decision about eligibil-
ity, we contacted authors to obtain further details.
Two review authors (A.L. and M.D.) performed the
data extraction independently using a data collection
form standardised beforehand by two authors (A.L. and
A-A.D.). Relevant extracted information included: study
design, population characteristics (e.g. number, age, sex
and principal health problem or diagnosis), context of the
intervention (e.g. characteristics of the LBST yogurt and of
the comparator(s) used, instructions given to participants,
methods for monitoring compliance), metabolic risk mark-
ers of chronic diseases assessed, adverse reactions and risk
of bias.
Assessment of risk of bias
consideration for change in body weight and/or nutritional
habits during the study, financial support and funding).
Each of the risk of bias items was assessed as “low risk”,
“high risk” and “unclear risk” in each of the included study
publications based on the Cochrane Handbook recommen-
dations [36]. Any discrepancies in judgement were resolved
by discussion and consensus, or with a third review author
(S.D.).
Data synthesis
As planned a priori, we grouped data with respect to meta-
bolic risk markers of chronic diseases. However, no meta-
analysis was performed due to considerable variation in
characteristics of the studies (e.g. comparator(s), dose
of yogurt, duration of the study). Within- and between-
treatment effects of LBST yogurt and comparators on
metabolic risk markers of chronic diseases are reported in
Table 3. The following paragraphs provide a narrative sys-
tematic review of these effects on risk markers evaluated in
included studies.

Two review authors (A.L. and A-A.D.) independently Results

assessed and reported on the risk of bias of included RCTs
in terms of the following individual elements: (1) random
sequence generation, (2) allocation concealment, (3) blind-
ing of participants and (4) of outcome assessors, (5) incom-
plete outcome data, (6) selective reporting and (7) other
possible bias (e.g. baseline imbalance between groups, no
Selection of included studies
Review authors first identified 3024 potentially relevant
publications (2986 from scientific databases, 37 from
references cited in the included studies and one from a

13

2986 records identified
Idenficaon
through electronic
searching
PubMed: 1484
EMBASE: 398
Cochrane library: 1104
Screening
2950 records after
duplicates removed
2950 records screened
Eligibility
435 full-text publications
assessed for eligibility
Included
7 studies included in review
(from 6 publications)
Fig. 1  PRISMA flow diagram of the study selection
published abstract conference). After removing duplicates,
2950 records were screened. From those, 2515 publica-
tions were excluded following the examination of titles and
abstracts and 435 full texts of the potentially relevant pub-
lications were retrieved for detailed evaluation. Three hun-
dred thirty-seven publications were classified as excluded
since at least one of our inclusion criteria was not met.
Ninety-one studies were classified as awaiting clas-
sification. From those, five studies contained insufficient
information to make a decision about eligibility despite an
attempt to communicate with their authors. Thirty-seven
studies were published as an abstract presented in a confer-
ence or as a registered protocol for a clinical trial and none
of those studies has been published as a full-text publica-
tion. Finally, we collaborated with a trial search coordina-
tor from the library of Laval University to find studies not
accessible via the Laval University library website. How-
ever, 49 full-text publications were still unavailable and
consequently the assessment of their eligibility was impos-
sible. A total of six publications (describing seven unique
studies) met all inclusion criteria and were included in the
review [37–42] (Fig. 1—PRISMA Flow Diagram). Supple-
mentary material 2 presents the references of studies await-
ing classification.
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Eur J Nutr
38 records identified
through other
sources
Included publications: 37
Related to published
conference abstract: 1
2515 records excluded
337 publications excluded
91 publications awaiting assessment
Full-text publications not found: 49
Abstract of clinical trial protocol (article not
published): 37
Missing details: 5
Characteristics of included studies
Characteristics of the seven studies included in this sys-
tematic review are presented in Table 2. All studies were
RCTs, of which three had a crossover design [37, 39, 42].
Studies were published in English between 1979 and 2014
and involved 278 adults aged 18 years and older. Four stud-
ies included both men and women [37, 38, 41], two stud-
ies included only men [39, 42] and one study included only
women [40]. The majority of the studies included healthy
adults. One study included both healthy adults and lactose
malabsorbers [39], and one study included only lactose
malabsorbers [37]. Two studies [38] were conducted in the
USA, one [39] in France, two [41, 42] in Canada, one [40]
in Iran and one [37] in Spain. Three studies included nor-
mal weight subjects [39, 40, 42], and four studies did not
specify weight nor body mass index of study participants
[37, 38, 41].
The quantity of strains used in LBST yogurt varied
among studies, ranging from 1 × 106 to 1.2 × 109 colony
forming units (CFU)/g. The quantity of LBST strains was
not reported in three studies [38, 42]. The dose of LBST
yogurt varied from 250 g/d to 1 L/d. The duration of the
LBST yogurt supplementation varied from one single dose,
 Table 2  Characteristics of included studies that have assessed the effect of LBST yogurt consumption on risk markers for chronic diseases in adults
First author, Country No. of partici- Sex Mean age y Study Intervention Risk markers
year pants enrolled (Range) design
Eur J Nutr

in study Strains (CFU/g); fat content Comparators Dose Duration for

(%) all compara-
tors

El Khoury Canada 20 health M 23.4 ± 0.57 RCT, LBST (ND)a; 0.38% Greek 250 g Once Blood glucose,
et al. [42] adults (ND) crossover strawberry- serum insulin
flavoured
yogurt,
Greek
honey-
flavoured
yogurt, skim
milk, orange
juice
Hepner et al. USA 18 healthy Intervention: LBST yogurt: RCT LBST (ND); ND 2% fat milk 720 mL/d 1 and 4 weeks Total choles-
[38] —study adults 3F/5M; 27.0 ± 4.0; terol, triglyc-
1 comparator: milk: erides
4F/6M 26.0 ± 3.0
(21.0–55.0)
Hepner et al. USA 36 healthy Intervention: LBST yogurt: RCT LBST (ND); ND Pasteurised 720 mL/d for 12 weeks Total choles-
[38] —study adults 6F/5M; 35.0 ± 10.0; yogurt, 2% all terol, triglyc-
2 comparator pasteurised fat milk, erides
1: 6F/4M; yogurt: Yogurt-free
comparator 39.0 ± 12.0; diet
2: 7F/3M; milk:
comparator 37.0 ± 12.0;
3: 4F/1M normal diet:
33.0 ± 6.0
(21.0–55.0)
Labayen et al. Spain 22 lactose 12F/10M 21.8 ± 1.6 RCT, LBST Pasteurised 500 mL/d 15 days Blood glucose,
[37] malabsorbers (ND) crossover (1.75 × 108 ± 3.4 × 108), ST yogurt serum insulin,
(5.93 × 108 ± 1.38 × 108); serum-free
ND fatty acids

13


Table 2  continued
First author, Country No. of partici- Sex Mean age y Study Intervention Risk markers
year pants enrolled (Range) design
Strains (CFU/g); fat content Comparators Dose Duration for

13
in study
(%) all compara-
tors
Rizkalla et al. France 12 lactase defi- M Lactase RCT, LBST (>107 for both strains); Pasteurised 500 g/d 15 days Plasma glucose,
[39] cient and 12 deficients: crossover 0.1% yogurt plasma insulin,
non-lactase 24.0 ±  2,0 ; plasma fatty
deficient non-lactase acids, plasma
deficients: acetate,
25.0 ± 1,0 plasma propi-
(20.0–60.0) onate, plasma
butyrate, total
cholesterol,
HDL-
cholesterol,
triglycerides
Sadrzadeh- Iran 90 healthy F LBST yogurt: RCT LBST (106–107 for both strains); Probiotic 300 g/d 6 weeks Total cho-
Yeganeh adults 32.0; probi- 2.5% yogurt lesterol,
et al. [40] otic yogurt: (LBST + L. triglycerides,
35.5; normal acidophilus HDL-choles-
diet: 34.7 La5 + B. terol, LDL-
(ND) lactis BB12) cholesterol,
yogurt-free total: HDL-
diet cholesterol
ratio
Thompson Canada 68 healthy 42F/26M 22.0 ± 4.0 RCT LBST (1.2 × 109 for both Skim milk, 1 L for all 3 weeks Total choles-
et al. [41] adults (ND) strains); 1.8% 2% fat milk, terol, HDL-
whole milk, cholesterol,
buttermilk, LDL-choles-
sweet acido- terol, triglyc-
philus milk erides

LBST, live cultures of L. delbrueckii subspecies bulgaricus and S. thermophilus; RCT, randomised controlled trials; CFU, colony forming units; ND, not described in studies; M, men; F, women
a
  Plain Greek yogurt prepared with live LBST cultures
Eur J Nutr
Eur J Nutr
to 12 weeks. Of the seven studies included in the system-
atic review, two used a control yogurt-free diet and moni-
tored subjects’ compliance with the study protocol through
weekly follow-ups by phones and 3-day dietary records
[40], or daily food logs [38].
Lipid profile
Total cholesterol
Five studies [38–41] assessed the effect of LBST yogurt on
total cholesterol concentrations. Hepner et al. [38] reported
a significant decrease in total cholesterol within the LBST
yogurt group after the supplementation of 720 ml/d of
LBST yogurt for one week in their two studies, and at
12 weeks but only in their second study [38]. Sadrzadeh-
Yeganeh et al. [40] showed a significant decrease in total
cholesterol within the LBST yogurt group after a six-week
supplementation of 300 g LBST yogurt/d. Rizkalla et al.
[39] showed no post-intervention effect after 500 g/d LBST
yogurt supplemented for 15 days, and Thompson et al.
[41] did not describe the within-treatment effect of the
LBST yogurt on total cholesterol concentrations. Regard-
ing between-treatment effects, Rizkalla et al. [39] com-
pared the impact of consumption of LBST yogurt and pas-
teurised yogurt and did not find a significant difference in
total cholesterol concentrations. Sadrzadeh-Yeganeh et al.
[40] found a significant decrease in total cholesterol after
a 6-week supplementation in LBST yogurt (300 g/d) com-
pared to a control yogurt-free diet.
LDL‑C
Two studies [40, 41] assessed the effect of LBST yogurt
on LDL-C concentrations. In regard to within-treatment
effects, none of these studies reported a significant change
in LDL-C concentrations following a 3-week nor a 6-week
LBST yogurt supplementation period. Thompson et al. [41]
reported no between-treatment effect of LBST yogurt (1 L/d)
and the comparators (i.e. skim milk, 2% fat milk, whole-fat
milk, buttermilk and sweet acidophilus milk) on LDL-C con-
centrations. Sadrzadeh-Yeganeh et al. [40] found no signifi-
cant changes in LDL-C concentrations after a 6-week supple-
mentation in LBST yogurt (300 g/d) compared to a control
yogurt-free diet nor a probiotic yogurt supplementation.
HDL‑C
Three studies [39–41] assessed the effects of LBST
yogurt on HDL-C concentrations. All studies showed no
post-intervention effect within the LBST yogurt group in
HDL-C concentrations. Compared to pasteurised yogurt,
Rizkalla et al. [39] showed no difference with the LBST
yogurt after a 15-day supplementation period (500 g/d) on
HDL-C concentrations, and Sadrzadeh-Yeganeh et al. [40]
found no significant changes in HDL-C concentrations after
a 6-week supplementation in LBST yogurt (300 g/d) com-
pared to a control yogurt-free diet and a probiotic yogurt
supplementation. Thompson et al. [41] did not describe the
comparative effect of a 3-week supplementation period in
LBST yogurt (1 L/d) and the comparators (skim milk, 2%
fat milk, whole-fat milk, buttermilk and sweet acidophilus
milk) on HDL-C concentrations.
Ratio of total cholesterol to HDL‑C
Sadrzadeh-Yeganeh et al. [40] assessed the effect of LBST
yogurt on the ratio of total cholesterol to HDL-C. This
study found a significant decrease in the ratio of total cho-
lesterol to HDL-C in subjects following a 6-week 300 g/d
LBST yogurt supplementation compared to a control
yogurt-free diet.
Triglycerides
Five studies [38–41] assessed the effect of LBST yogurt on
triglyceride concentrations. Thompson et al. [41] showed a
significant increase in triglycerides after a 3-week supple-
mentation within the LBST yogurt group (1 L/d), whereas
the four other studies [38–40] showed no within-treatment
effect of the LBST yogurt on triglyceride concentrations.
When comparing the mean differences between baseline
and 15-day of 500 g/d supplementation for triglyceride con-
centrations, Rizkalla et al. [39] found no statistically sig-
nificant difference between LBST yogurt and pasteurised
yogurt groups. Sadrzadeh-Yeganeh et al. [40] also found no
significant change between baseline and a 6-week 300 g/d
supplementation in triglyceride concentrations among
LBST yogurt, probiotic yogurt and control yogurt-free diet
groups. No other study described between-treatment effects
on triglyceride concentrations.
Glucose homoeostasis
Plasma glucose
Two studies [37, 39] assessed the effects of LBST yogurt on
the area under the curve (AUC) for glucose concentrations.
Rizkalla et al. [39] showed no post-intervention effect after
a 15-day LBST yogurt supplementation period (500 g/d)
on AUC for fasting plasma glucose. Labayen et al. [37] did
not describe these effects. Both studies showed no differ-
ence between LBST yogurt and pasteurised yogurt used as
a comparator on the AUC for glucose concentrations.
13

In a crossover study, El Khoury et al. [42] investigated
the effects on the incremental area under the curve (iAUC)
for blood glucose changes from baseline to 120 min after
the consumption of 250 g of plain LSBT Greek yogurt and
four comparators (i.e. strawberry-flavoured Greek yogurt,
honey-flavoured Greek yogurt, skim milk and orange
juice). This study showed that plain LBST Greek yogurt
produced significantly lower glucose elevations compared
to strawberry-flavoured Greek yogurt and orange juice.
Plasma insulin
Two studies [37, 39] assessed the effects of LBST yogurt
on the AUC for blood insulin. Rizkalla et al. [39] showed
no post-intervention effect after a 15-day LBST yogurt sup-
plementation period (500 g/d) on AUC for fasting plasma
insulin. Labayen et al. [37] did not describe these effects.
Both studies showed no difference between the LBST
yogurt and the pasteurised yogurt used as a comparator on
the AUC for insulin concentrations.
El Khoury et al. [42] assessed, in a sub-sample of 15
healthy males, the effects on iAUC for serum insulin
changes from baseline to 120 min after the consumption of
250 g of plain LSBT Greek yogurt and four comparators
(i.e. strawberry-flavoured Greek yogurt, honey-flavoured
Greek yogurt, skim milk and orange juice). No significant
changes were observed between the experimental groups
on the iAUC for serum insulin.
Short‑chain fatty acids
Two studies [37, 39] assessed the effect of LBST yogurt on the
AUC for plasma fatty acid concentrations. Rizkalla et al. [39]
showed no post-intervention effect of a 15-day LBST yogurt
supplementation period (500 g/d) on the AUC for short-chain
fatty acids in both subjects with lactose malabsorption and
without lactose malabsorption. Labayen et al. [37] did not
describe this effect. Both studies showed no difference between
the LBST yogurt and the comparator (i.e. pasteurised yogurt)
on the AUC for plasma-free fatty acid concentrations (Table 3).
Rizkalla et al. [39] investigated the AUC for plasma
acetate, propionate and butyrate concentrations in both sub-
jects with and without lactose malabsorption. In their study,
no significant difference was observed in either AUC for
plasma acetate or butyrate after a 15-day LBST yogurt sup-
plementation period, whereas a significant increase in the
AUC for plasma propionate was observed after supplemen-
tation in LBST yogurt (500 g/d) in subjects with lactose
malabsorption only. No difference between LBST yogurt
and the comparator (i.e. pasteurised yogurt) was found in
AUC for plasma acetate. The AUC of the plasma butyrate
was higher after LBST yogurt supplementation than after
pasteurised yogurt supplementation in subjects without
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Eur J Nutr
lactose malabsorption. A tendency for a significantly higher
AUC of the plasma propionate was also observed after the
supplementation with LBST yogurt than after the pasteur-
ised yogurt supplementation in subjects without lactose
malabsorption (P < 0.059).
Risk of bias within included studies
As shown in Table 4, seven risks of bias criteria were
assessed in each study as recommended by the Cochrane
Collaboration [36]. For the first criterion, the random
sequence generation was unclear in the majority of
included studies, as only one study [42] reported sufficient
information to assess this risk of bias. For the second crite-
rion, six studies [37–40, 42] out of seven did not describe
the allocation concealment in sufficient detail to permit
evaluation, resulting in an unclear risk of bias. Thompson
et al. [41] did not respect allocation concealment, as one
individual was reallocated to an alternative experimental
group due to inability to take the full experimental supple-
ment as originally assigned during the study period, result-
ing in a high risk of bias. One study [39] did not explic-
itly describe the blinding of participants, resulting in an
unclear risk of bias. For the third criterion, the blinding of
participants to the assigned intervention was impossible in
four studies due to the nature of the tested products (e.g.
milk versus LBST yogurt) [38, 41, 42]. Blinding of out-
come assessors was not explicitly described in five stud-
ies [38, 39, 41, 42]. Regarding the fourth criterion, three
studies [39, 40, 42] adequately addressed incomplete out-
come data, whereas, missing outcome data from four sub-
jects who were withdrawn for personal reasons as the study
proceeded raised the possibility that the observed effect
estimate may be biased in one study [37]. Moreover, three
studies [38, 41] did not provide sufficient details to evalu-
ate this criterion, resulting in an unclear risk of bias. For
the fifth criterion, no study had a protocol available to eval-
uate if pre-specified outcomes that were of interest in the
study were reported in the pre-specified way, resulting in
an unclear risk of bias. Regarding the last criterion of risk
of bias from other sources, five studies [38–42] had a high
risk of bias determined by no consideration of baseline val-
ues for characteristics strongly associated with metabolic
risk markers or a change in weight and/or nutritional hab-
its during the intervention not considered in the statistical
analyses. Indeed, no significant change in nutritional habits
between groups was observed in both studies conducted by
Hepner et al. [38]. However, weight change was different
according to groups and no consideration in statistical anal-
yses was undertaken. In a study by Thompson et al. [41],
no consideration was given for baseline nutritional and
weight values. Baseline imbalance in these characteristics
did not apply to El Khoury et al. [42] and Labayen et al.
 Table 3  Summary of observed changes in risk markers for chronic diseases assessed in included studies
Risk markers First author, year Duration Effect of LBST yogurt Effect of comparators Difference between treatment
Eur J Nutr

△ from baseline P Name △ from baseline P △ from baseline P

Total cholesterol Hepner et al. 1 week Not described <0.01 2% fat milk Not described Uncleara Not described Not described
[38] —study 1 4 weeks Not described Not described Not described Uncleara Not described Not described
Hepner et al. 1 week Not described <0.01 Pasteurised Not described <0.01 Not described Not described
[38] —study 2 12 weeks Not described <0.01 yogurt Not described <0.01 Not described Not described
2% fat milk Not described <0.05 Not described Not described
Not described <0.05 Not described Not described
Yogurt-free Not described Not described Not described Not described
dietb Not described Not described Not described Not described
Rizkalla et al. 15 days Not described NS Pasteurised Not described NS Not described NS
[39] yogurt
Sadrzadeh- 3 weeks Not described Not described Probiotic Not described Not described Not described Not described
Yeganeh et al. 6 weeks <0.05 yogurt <0.01 Not described NS
[40]
−0.13 mmol/L ± 0.36 −0.2 mmol/L ± 0.33
Yogurt-free Not described Not described Not described Not described
diet 0.18 mmol/L ± 0.51 NS Not described <0.05
Thompson et al. 3 weeks Not described Not described Skim milk Not described Not described Not described Not described
[41] 2% fat milk Not described Not described Not described Not described
Whole milk Not described Not described Not described Not described
Buttermilk Not described Not described Not described Not described
Sweet acido- Not described Not described Not described Not described
philus milk
LDL-cholesterol Sadrzadeh- 3 weeks Not described Not described Probiotic Not described Not described Not described Not described
Yeganeh et al. 6 weeks NS yogurt NS Not described NS
[40]
−0.03 mmol/L ± 0.24 −0.06 mmol/L ± 0.29
Yogurt-free Not described Not described Not described Not described
diet 0.08 mmol/L ± 0.43 NS Not described NS
Thompson et al. 3 weeks Not described NS Skim milk Not described NS Not described Not described
[41] 2% fat milk Not described NS Not described Not described
Whole milk Not described NS Not described Not described
Buttermilk Not described NS Not described Not described
Sweet acido- Not described NS Not described Not described
philus milk

13


Table 3  continued
Risk markers First author, year Duration Effect of LBST yogurt Effect of comparators Difference between treatment

△ from baseline P Name △ from baseline P △ from baseline P

13
HDL-Cholesterol Rizkalla et al. 15 days Not described NS Pasteurised Not described NS Not described NS
[39] yogurt
Sadrzadeh- 3 weeks Not described Not described Probiotic Not described Not described Not described Not described
Yeganeh et al. 6 weeks 0.07 mmol/L ± 0.17 NS yogurt 0.11 mmol/L ± 0.15 <0.01 Not described NS
[40]
Yogurt-free Not described Not described Not described Not described
diet −0.01 mmol/L ± 0.13 NS Not described NS
Thompson et al. 3 weeks Not described NS Skim milk Not described NS Not described Not described
[41] 2% fat milk Not described NS Not described Not described
Whole milk Not described NS Not described Not described
Buttermilk Not described NS Not described Not described
Sweet acido- Not described NS Not described Not described
philus milk
Total: HDL-choles- Sadrzadeh- 3 weeks Not described Not described Probiotic Not described Not described Not described Not described
terol ratio Yeganeh et al. 6 weeks <0.01 yogurt <0.01 Not described NS
[40]
−0.01 mmol/L ± 0.01 −0.01 mmol/L ± 0.01
Yogurt-free Not described Not described Not described Not described
diet 0.01 mmol/L ± 0.02 NS Not described <0.01
Triglycerides Hepner et al. 1 week Not described NS 2% Milk Not described NS Not described Not described
[38] —study 1 4 weeks Not described NS Not described Uncleara Not described Not described
Hepner et al. 1 week Not described Not described Pasteurised Not described Not described Not described Not described
[38] —study 2 4 weeks Not described Not described yogurt Not described Not described Not described Not described
12 weeks Not described NS Not described NS Not described Not described
2% fat milk Not described Not described Not described Not described
Not described Not described Not described Not described
Not described NS Not described Not described
Yogurt-free Not described Not described Not described Not described
dietb Not described Not described Not described Not described
Not described Not described Not described Not described
Rizkalla et al. 15 days Not described NS Pasteurised Not described NS Not described NS
[39] yogurt
Sadrzadeh- 3 weeks Not described Not described Probiotic Not described Not described Not described Not described
Yeganeh et al. 6 weeks 0.03 mmol/L ± 0.13 NS yogurt 0.0 mmol/L ± 0.3 NS Not described NS
[40]
Yogurt-free Not described Not described Not described Not described
diet 0.08 mmol/L ± 0.26 NS Not described NS
Thompson et al. 3 weeks 11.3 mg/100 mL plasma ± 4.3 <0.05 Skim milk Not described Not described Not described Not described
[41] 2% fat milk Not described Not described Not described Not described
Whole milk Not described Not described Not described Not described
Buttermilk Not described Not described Not described Not described
Sweet acido- 11.8 mg/100 mL <0.05 Not described Not described
philus milk plasma ± 5.1
Eur J Nutr
 Table 3  continued
Risk markers First author, year Duration Effect of LBST yogurt Effect of comparators Difference between treatment
Eur J Nutr

△ from baseline P Name △ from baseline P △ from baseline P

Plasma glucosec,d,e El Khoury et al. 120 min Not described Not described Greek Not described Not described Not described <0.05
[42] strawberry-
flavoured
yogurt
Greek honey- Not described Not described Not described NS
flavoured
yogurt
Skim milk Not described Not described Not described NS
Orange juice Not described Not described Not described <0.05
Labayen et al. 15 days −45.4 mmol/L.min ± 19.3 Not described Pasteurised Not described Not described Not described NS
[37] yogurt
Rizkalla et al. 15 days Not described NS Pasteurised Not described NS Not described NS
[39] yogurt
Plasma insulinc,d,e El Khoury et al. 120 min Not described Not described Greek Not described Not described Not described NS
[42] strawberry-
flavoured
yogurt
Greek honey- Not described Not described Not described NS
flavoured
yogurt
Skim milk Not described Not described Not described NS
Orange juice Not described Not described Not described NS
Labayen et al. 15 days 1822.9 mU/L min ± 684.0 Not described Pasteurised Not described Not described Not described NS
[37] yogurt
Rizkalla et al. 15 days Not described NS Pasteurised Not described NS Not described NS
[39] yogurt

13


Table 3  continued
Risk markers First author, year Duration Effect of LBST yogurt Effect of comparators Difference between treatment

△ from baseline P Name △ from baseline P △ from baseline P

13
Plasma fatty acidsd,e Labayen et al. 15 days 54.7 mmol/L min ± 3.64 Not described Pasteurised Not described Not described Not described NS
[37] yogurt
Rizkalla et al. 15 days Not described NS Pasteurised Not described NS Not described NS
[39] yogurt
Plasma acetatee Rizkalla et al. 15 days Not described NS Pasteurised Not described NS Not described NS
[39] yogurt
Plasma butyratee Rizkalla et al. 15 days Not described NS Pasteurised Not described NS Not described <0.03f
[39] yogurt
Plasma propionatee Rizkalla et al. 15 days Not described <0.04f Pasteurised Not described NS Not described NS
[39] yogurt

Values are mean differences ± SD or SEMs of change from baseline. LBST yogurt, yogurt fermented with live cultures of L. delbrueckii subspecies bulgaricus and S. thermophilus; △, signifi-
cant change from baseline; NS, non-significant
a
  In Hepner et al. study 1, the participants were divided into 2 groups: Group A (LBST yogurt, wash-out, comparator) and Group B (comparator, wash-out, LBST yogurt). The effect on total
cholesterol was not significant in Group B but was not described in Group A after 1-week milk supplementation; The effect of milk on total cholesterol was not significant in Group A but was
not described in Group at week 4; and triglycerides decreased significantly (P < 0.01) in Group B but not in Group A after 4-week milk supplementation
b
  In Hepner et al. study 2, the control group consuming yogurt-free diet was studied for 6 weeks, as opposed to the other experimental groups that were studied for 6 and 12 weeks
c
  El Khoury et al. reported values as plasma glucose (mmol min/L) and serum insulin (µU min/mL) incremental areas under the curve (iAUCs) of mean changes form baseline (0 min) to
120 min after consumption of LBST yogurt and comparators
d
  Labayen et al. reported values as AUCs (mmol/L min) for blood glucose concentrations, serum insulin concentrations and serum-free fatty acid concentrations after 15-day of LBST and pas-
teurised yogurt supplementation periods
e
  Rizkalla et al. reported values as areas under the curve (AUCs) for plasma glucose (mmol 3 h/L), plasma insulin (pmol 3 h/L) and plasma fatty acids (μmol 3 j/L) over 3 h after a load of
LBST and pasteurised yogurt at the beginning (day 0) and at the end (day 15) of each supplementation period
f
  In Rizkalla et al. study, within-treatment analysis showed that a significant elevation of the plasma propionate AUC after 15-day LBST yogurt supplementation compared with baseline in sub-
jects with lactose malabsorption. AUCs for plasma butyrate were higher after LBST yogurt supplementation than after pasteurised yogurt supplementation in subjects without lactose malabsorp-
tion
Eur J Nutr
Eur J Nutr

Table 4  Summary of the risk of bias in included studies as recommended by the Cochrane Collaboration (n = 7 studies)
Study Criteria
Random Allocation Blinding of Blinding Incomplete Selective Other biasg
sequence concealmentb participantsc of outcome outcome datae outcome
generationa assessorsd reportingf

El Khoury et al. Low risk Unclear risk High risk Unclear risk Low risk Unclear risk High risk
[42]
Hepner et al. Unclear risk Unclear risk High risk Unclear risk Unclear risk Unclear risk High risk
[38] —study 1
Hepner et al. Unclear risk Unclear risk High risk Unclear risk Unclear risk Unclear risk High risk
[38] —study 2
Labayen et al. Unclear risk Unclear risk Low risk Low risk High risk Unclear risk Unclear risk
[37]
Rizkalla et al. Unclear risk Unclear risk Unclear risk Unclear risk Low risk Unclear risk High risk
[39]
Sadrzadeh- Unclear risk Unclear risk Low risk Low risk Low risk Unclear risk High risk
Yeganeh et al.
[40]
Thompson et al. Unclear risk High risk High risk Unclear risk Unclear risk Unclear risk High risk
[41]
a
  Random sequence generation, describes the method used to generate the allocation sequence in sufficient detail to allow an assessment of
whether it should produce comparable groups
b
  Allocation concealment, describes the method used to conceal the allocation sequence in sufficient detail to determine whether intervention
allocations could have been foreseen in advance of, or during, enrolment
c,d
  Blinding of participants and blinding of outcome assessors, describe all measures used to blind study participants and personnel from knowl-
edge of which intervention a participant received and provide any information relating to whether the intended blinding was effective
e
  Incomplete outcome data, describe the completeness of outcome data for each main outcome and states whether attrition and exclusions were
reported, the numbers in each intervention group, reasons for attrition/exclusions were reported, and any re-inclusions in analyses performed by
the review authors
f
  Selective reporting, states how the possibility of selective outcome reporting was examined by the review authors and what was found
g
  Other possible bias, describes the presence of baseline imbalance between groups, no consideration for change in body weight and/or nutri-
tional habits during the study and/or report financial support and funding

[37] due to their crossover design. Rizkalla et al. [39] did
not measure change in nutritional habits nor weight during
the study, resulting in a high risk of bias. In addition, six
studies [38–42] out of seven were funded by a dairy prod-
uct company or dairy product associations, which in turn
resulted in the possibility of a high risk of bias for this last
criterion of other potential sources of bias. Labayen et al.
[37] reported insufficient information to assess the last cri-
terion of other potential sources of bias (i.e. no baseline
data, no measure of weight change or nutritional data and
no mention of study funding), resulting in an unclear risk
of bias.
Discussion
Summary of main results
The present study systematically reviewed the evidence
from RCTs regarding the effect of LBST yogurt con-
sumption on metabolic risk markers of chronic diseases in
adults. We first observed that this topic was rarely studied,
as only seven RCTs meeting the eligibility criteria were
found. A large number of records were not assessed for
relevance to the review because their full text could not be
obtained despite attempts to communicate with authors.
Most included studies [38, 40–42] were undertaken in
healthy adults, and two studies were conducted among lac-
tose malabsorbers [37, 39]. These last two studies contrast
with the other included studies, as their primary aim was
to enhance knowledge on lactose malabsorption symptoms
and lactose digestion after the ingestion of LBST yogurt
when compared with pasteurised yogurt [37] or to assess
whether these metabolic effects differed between subjects
with and without lactose malabsorption [39].
In addition, limited metabolic risk markers contributing
to the aetiology of common chronic diseases in regard to
conventional LBST yogurt consumption have so far been
investigated in randomised controlled settings among
adults. Indeed, we only identified studies assessing mark-
ers related to blood lipids, short-chain fatty acids and
glucose homoeostasis. Data from our systematic review

13

suggest that consumption of LBST yogurt exerts either
favourable or neutral effect on total cholesterol concen-
trations, ratio of total cholesterol to HDL-C and plasma
glucose when compared to a control treatment. These find-
ings must be interpreted with caution since studies had
different comparators and assessment points and globally
showed high to unclear methodological risks of bias. Thus,
we cannot draw conclusions on the biological mechanisms
underlying the consumption of LBST yogurt on meta-
bolic risk markers of chronic diseases based on available
evidence.
LBST yogurt consumption, blood lipids and short‑chain
fatty acids
The two studies reporting significant favourable post-inter-
vention effects of LBST yogurt on total cholesterol and on
the ratio of total cholesterol to HDL-C [40] or butyrate con-
centrations [39] compared to the comparators had impor-
tant methodological differences limiting proper compari-
son of results. Rizkalla et al. [39] compared, in a crossover
study design, the consumption of 500 g/d of low-fat yogurt
(0.1%) with (fresh) or without (heated) live LBST bacte-
ria cultures in both lactase-deficient and non-lactase-defi-
cient male subjects in France. The supplementation lasted
15 days and did not generate significant changes in blood
lipids between yogurt groups. This finding may be attribut-
able to the short duration of the intervention, which may
have prevented detection of any effects. A more recent
study conducted by Sadrzadeh-Yeganeh et al. [40] tested
in a three-arm parallel group RCT the effect of 300 g/d of
LBST yogurt and 300 g/d probiotic yogurt, enriched with
Lactobacillus acidophilus La5 and Bifidobacterium lactis
Bb12, supplemented for 6 weeks, compared to a control
yogurt-free diet, on the lipid profile of 90 healthy women
in Iran. This study showed that LBST yogurt significantly
reduced total cholesterol concentrations and the ratio of
total cholesterol to HDL-C compared to the control yogurt-
free diet. These positive effects of yogurt on the lipid pro-
file may be attributed to specific dietary components of
yogurt, including calcium and bioactive peptides. It has
been shown that increased calcium intake from dairy prod-
ucts attenuates postprandial lipid response, most probably
through the interference of calcium with fat absorption in
the intestine by the formation of calcium soaps with fatty
acids and/or binding of bile acids, thereby accentuating
faecal fat loss [43, 44]. The beneficial effects of yogurt
consumption in the modulation of the lipid profile may
further be attributed to specific milk-derived bioactive
peptides, such as lactostatin derived from bovine protein
beta-lactoglobulin, which may play an important role in the
prevention and treatment of the metabolic syndrome and
13
Eur J Nutr
its complication [45] through several mechanisms includ-
ing decreasing cholesterolemia [46]. Nonetheless, clear
conclusions of the impact of LBST yogurt per se on risk
markers of chronic diseases related to blood lipids cannot
be drawn from these two studies [39, 40], due to the dif-
ferences regarding the composition of tested yogurts, i.e.,
strains (probiotics or heated versus live LBST cultures),
in addition to methodological differences in regard to sex
and health status of study participants, as well as lengths of
supplementation periods.
LBST yogurt consumption and glucose homoeostasis
Two studies [37, 39] investigated risk markers related to
glucose homoeostasis in adults with lactose malabsorption,
but failed to detect significant changes following the LBST
yogurt supplementation compared to pasteurised yogurt
containing inactive lactic bacteria. In a crossover study,
El Khoury et al. [42] compared the postprandial glucose,
insulin, satiety and food intake, following a single 250 g
intake of plain LSBT Greek-style yogurt compared to four
other treatments composed of lower protein to carbohy-
drate ratios (i.e. Greek-flavoured yogurt, milk and orange
juice) in 20 healthy Canadian adults. Due to the different
nutritional composition of the LBST yogurt, this study
consequently cannot be compared to the other included
studies investigating glucose homoeostasis. Indeed, Greek-
style yogurt has an elevated protein content in the range
of 15–20 g/serving of 175 g [47], which represents twice
the protein content of conventional LBST yogurt usually
containing 10 g of protein/serving. In this study [42], the
authors’ hypothesis that Greek-style yogurt consumption
as an afternoon snack would lead to improved control of
glycaemia than milk was rejected, as all dairy treatments
(i.e. Greek-style yogurts and milk) lowered glycaemic
responses compared to orange juice, independently of their
protein to carbohydrate contents. The improved glucose
control post-treatment consumption was not linked to an
enhanced efficacy of insulin activity in El Khoury et al.
study [42]. This is corroborated by results of previous
studies that have demonstrated that whey fraction of milk
proteins, when consumed prior to a meal, may improve
post-meal glycaemic control by insulin-independent mech-
anisms (e.g. gastric emptying through the release of chol-
ecystokinin and glucagon-like peptide 1 [48]) in healthy
adults [49, 50]. Evidence from a recent clinical trial dem-
onstrated that functionality of milk products is not read-
ily predicted from the composition of their macronutrients
alone in regards to glycaemic control and gut hormones
[50]. Thus, more evidence from RCTs is needed to con-
clude on the effects of LBST consumption per se on gly-
caemic control.
Eur J Nutr
Study quality, bias and applicability of evidence
Differences in the nutritional composition of LBST yogurt
and other dairy products used as comparators can further
explain the heterogeneous results observed among included
studies. Dairy fatty acid content [51, 52], calcium [53–55]
and vitamin D [56, 57] content, bioactive dairy peptides
[58–60], as well as trans-palmitoleic acid [61, 62], are
among dairy product components that have been shown
to potentially influence the impact of yogurt on health
outcomes. Marette and Picard-Deland [25] recently pro-
posed the idea that yogurt is a unique food matrix that may
enhance nutrient bioavailability and provide potential ben-
efits on obesity and cardiovascular risk. In included stud-
ies of the present review, dairy products used as treatment
and comparators, such as yogurt and milk, had heteroge-
neous fat contents, protein concentrations, bacterial strains,
as well as possibly different dairy fatty acid compositions.
Half of included studies failed to document the fat content
of LBST yogurt and comparators, and the number of LBST
strains used in the experimental yogurt was not described
in the 3 studies [38, 42]. Only Thompson et al. [41] docu-
mented the calcium content of LBST yogurt, but without
further consideration to its potential effect on blood choles-
terol and triglyceride concentrations. No study considered
vitamin D supplementation within experimental products.
The consumption of yogurt enriched in vitamin D has been
associated with improved glycaemic status in individu-
als with type 2 diabetes in some studies [57, 63]. Moreo-
ver, the various countries where included studies were
conducted (i.e. the USA, Canada, France, Spain and Iran)
further limit generalisation of results. It has been shown
that different dairy farming practices across countries, par-
ticularly bovine feeding from pasture or concentrates, can
substantially affect the fatty acid profiles of milk and dairy
products [64, 65]. The main geographic disparities can be
observed in conjugated linoleic acids, vaccenic acid, trans-
palmitoleic acid, phytanic acid, alpha-linoleic acid and
C12-C16 saturated fatty acid concentrations [52], none of
which were documented in the nutritional composition of
LBST yogurt and dairy products used as comparators in
included studies of the present systematic review.
Interestingly, only one study [40] compared a LBST
supplemented diet to a control usual diet not supplemented
with any other treatment. Indeed, the study by Sadrzadeh-
Yeganeh et al. [40] is, to our knowledge, the only RCT ever
reporting significant change post-LBST yogurt supplemen-
tation compared to a control diet not supplemented with
another treatment on metabolic risk markers of chronic
diseases. Thus, further large-scale well-designed RCTs
comparing a usual diet, to a diet in which LBST yogurt is
added, are needed to confirm epidemiological evidence of
yogurt health benefits [19–22, 66, 67]. This comparison is
all the more important to enable clear conclusions about
whether inclusion of regular yogurt in people’s usual diet
would be an effective strategy to improve metabolic risk
markers of chronic diseases.
The risk of bias in the included studies appeared gen-
erally high, but there were many risks of bias criteria that
were left unclear as information for assessment was not
available. No study met the eight criteria of risk of bias.
Among those eight criteria, the majority of included stud-
ies provided insufficient information for the assessment of
the random sequence allocation of treatments, the alloca-
tion concealment of treatments and the selective reporting
of outcomes. Four studies (out of seven) did not blind the
participants and did not specify if outcome assessors were
blind to the experimental treatments. In the majority of the
research settings, blinding was limited, if not impossible,
due to the appearance of the comparators (e.g. liquid LBST
yogurt versus flavoured milk or orange juice). Future stud-
ies need to fill the gaps in the reporting of items associated
with the risk of biased results. For this matter, worldwide
systematic reporting tools, such as the CONSORT 2010
statement [68], have been developed to guide authors in
complete, clear and transparent reporting of RCTs.
Potential biases in the review process
To our knowledge, no prior study has systematically
reviewed the effect of conventional LBST yogurt con-
sumption on metabolic risk markers of chronic diseases.
Strengths of this systematic review include the rigor-
ous methodology, including the collaboration with a trial
search coordinator from the library of Laval University
to gather additional information during data collection.
This was done to optimise the number of included studies
when experimental products used in studies (e.g. yogurt
strains used) were not adequately described. We systemati-
cally searched three large scientific databases relevant for
peer-reviewed biomedical literature. However, we cannot
exclude the possibility that we missed studies indexed in
other scientific or food databases. Additional relevant stud-
ies may also be contained in the studies that could not be
assessed for relevance to the review due to the impossibil-
ity to obtain their full text despite attempts to communicate
with authors.
The present systematic review was also subject to some
limitations that need to be acknowledged. Our systematic
literature search yielded a limited number of studies that
have focussed on the impact of LBST yogurt consump-
tion on metabolic risk markers of chronic diseases meeting
the WHO definition [1]. Seven studies had to be excluded
as they solely investigated the impact of LBST yogurt on
lactose intolerance and digestive symptoms. We identi-
fied several RCTs that had evaluated the effectiveness of
13

the consumption of probiotic yogurt on risk markers of
chronic diseases in comparison with a control supplemen-
tation of LBST yogurt. These RCTs were thus ineligible
for the review and likely had inadequate power to detect
the effectiveness of LBST yogurt when used as a control
or placebo. Finally, most included studies were conducted
among healthy adults. Future studies are therefore needed
to assess the effect of LBST yogurt on risk markers of
chronic diseases in various populations, notably chroni-
cally ill patients.
Conclusions
In conclusion, limited RCTs on the effect of LBST yogurt
consumption on metabolic risk markers of chronic diseases
in adults have so far been conducted, and only one study
assessed these effects in comparison with a control yogurt-
free diet. Data from this systematic review indicate that
the consumption of LBST yogurt shows either favourable
or neutral effect on metabolic risk markers of cardiovas-
cular disease and diabetes when compared with a control
treatment in controlled research settings. Further rigor-
ously designed, well-controlled and adequately powered
RCTs are needed to evaluate the effect of the inclusion of
LBST yogurt in the diet per se on metabolic risk factors for
chronic diseases, as well as on emerging cardiometabolic
risk markers, such as subclinical inflammation [69] and
vascular dysfunction [70]. Epidemiological evidence seems
to support the association between yogurt consumption and
a better diet quality [31–34], as well as its potential impact
for counteracting chronic diseases such as type 2 diabetes.
Nevertheless, more evidence from well-designed interven-
tion studies is needed to further increase our understand-
ing of the mechanisms underlying the beneficial impact of
yogurt on health and chronic disease prevention and man-
agement in adults.
Financial support  The Danone Institute of Canada funded this study
and had no role in the analysis or writing of this article. A.-A. D. is
a recipient of a master’s scholarship from the Canadian Institutes of
Health Research (CIHR) funded Knowledge Translation Student
Fellowship and Training Program, and a doctoral scholarship from
the Fonds de recherche en santé du Québec. S.D. is a CIHR New
Investigator.
Compliance with ethical standards  National Heart L, Blood I, American Heart A (2004) Definition
Conflict of interest  S.D. received funding from the Danone Institute.
Over the past five years, V.P. has received honoraria and travel expense
reimbursement for participating in two symposia organised by Dairy
Farmers of Canada. V.P. was also the principal investigator on a grant
from the Dairy Research Cluster (Dairy Farmers of Canada, Agricul-
ture and Agri-Food Canada, and the Canadian Dairy Commission).
B.L. is Chair of Nutrition at Laval University, which Board of Direc-
tors include a representative from Provigo–Loblaws. B.L. has received
13
Eur J Nutr
funding from Agri-food and Agriculture Canada, the Dairy Farmers of
Canada (DFC), Dairy Australia to study dairy and health. He serves as
the Chair of the independent, peer-review Expert Scientific Advisory
Council of DFC. B.L. has also received honoraria from DFC as an
invited speaker in various conferences.
Authorship The authors’ responsibilities were as follows—S.D.,
A.L., B.L. and V.P. designed the study; A.L., M.D. and A.-A.D. con-
ducted the search and extracted data; A.L. and A.-A.D. performed the
analysis of the risk of bias within studies; A.-A.D. wrote the manu-
script; and S.D. had primary responsibility for the final content. All of
the authors critically reviewed the manuscript and approved its final
version.
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