The n e w e ng l a n d j o u r na l of m e dic i n e
C or r e sp ondence
Milk and Health
To the Editor: Excess body fat and obesity are
the major causes of type 2 diabetes, and they
contribute to both cardiovascular disease and
cancer. It is therefore important to identify foods
that can contribute to reducing obesity. The re-
view article by Willett and Ludwig (Feb. 13 issue)1
on the effect of dairy consumption on body weight
overlooks important information on this topic.
The authors cite a meta-analysis of randomized,
controlled trials on dairy foods and conclude
that no effect on body weight was seen.2 The
meta-analysis actually showed that dairy con-
sumption decreased body fat mass. These find-
ings, which are in line with those of other meta-
analyses that also showed preservation of lean
body mass, emphasize the importance of looking
not only at body weight, but also at body compo-
sition.3
A meta-analysis of observational studies in-
volving 46,011 children and adolescents showed
that children with the highest intake of dairy
were 38% less likely to become overweight or
obese than those with lower intake.4 The most
comprehensive systematic review of both obser-
vational studies and randomized, controlled trials
showed that milk and dairy products are con-
sistently not associated, or are inversely associ-
ated, with obesity and indicators of adiposity in
children.5,6
Arne Astrup, M.D., D.M.Sc.
University of Copenhagen
Copenhagen, Denmark
ast@​­nexs​.­ku​.­dk
Dr. Astrup reports receiving travel expenses and honoraria
for lectures given at international meetings from the European
Milk Forum and research funding from Arla Food for Health.
No other potential conflict of interest relevant to this letter was
reported.
1. Willett WC, Ludwig DS. Milk and health. N Engl J Med 2020;​
382:​644-54.
2. Chen M, Pan A, Malik VS, Hu FB. Effects of dairy intake on
body weight and fat: a meta-analysis of randomized controlled
trials. Am J Clin Nutr 2012;​96:​735-47.
3. Geng T, Qi L, Huang T. Effects of dairy products consump-
tion on body weight and body composition among adults: an
updated meta-analysis of 37 randomized control trials. Mol Nutr
Food Res 2018;​62:​(1).
n engl j med 382;23
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4. Lu L, Xun P, Wan Y, He K, Cai W. Long-term association
between dairy consumption and risk of childhood obesity: a sys-
tematic review and meta-analysis of prospective cohort studies.
Eur J Clin Nutr 2016;​70:​414-23.
5. Colquitt JL, Loveman E, O’Malley C, et al. Diet, physical ac-
tivity, and behavioural interventions for the treatment of over-
weight or obesity in preschool children up to the age of 6 years.
Cochrane Database Syst Rev 2016;​3:​CD012105.
6. Dougkas A, Barr S, Reddy S, Summerbell CD. A critical re-
view of the role of milk and other dairy products in the develop-
ment of obesity in children and adolescents. Nutr Res Rev 2019;​
32:​106-27.
DOI: 10.1056/NEJMc2005220
To the Editor: Willett and Ludwig evaluated
evidence on health effects of milk in light of its
long-standing presence in nutrition guidelines.
Although we agree with the intent of the review
article, we suggest the authors overlooked several
areas of evidence on milk and children’s health.
For example, cow’s milk was identified as a bev-
erage for children if breast milk is unavailable.
However, no current recommendation suggests
that cow’s milk should replace breast milk; rath-
er, it is recommended for older children who are
no longer breast-feeding.1
We agree with the authors that, on the basis
of the available evidence, guidelines should de-
emphasize reduced-fat milk as being preferable to
whole milk.2,3 However, we disagree that limited
data exist regarding milk and children’s health.
The authors cite research from 1976 by Baker and
colleagues. That trial did not use modern meth-
ods, including standardized anthropometric mea-
sures or adjustment for confounding variables.
Considerable research since then providing a
more complete evaluation of these relationships
appears to have been overlooked. Several review
articles and meta-analyses on milk and chil-
dren’s health and adiposity are available.4
Shelley Vanderhout, R.D., M.Sc.
Jonathon L. Maguire, M.D.
Unity Health Toronto
Toronto, ON, Canada
jonathon​.­maguire@​­utoronto​.­ca
No potential conflict of interest relevant to this letter was
reported.
nejm.org June 4, 2020 e86(1)
 The n e w e ng l a n d j o u r na l of m e dic i n e

1. The optimal duration of exclusive breastfeeding:​report of an vitamin D status.” This caveat is most appropriate.
expert consultation. Geneva:​World Health Organization, 2002.
Although meta-analyses have shown positive,
2. Drehmer M, Pereira MA, Schmidt MI, et al. Total and full-
fat, but not low-fat, dairy product intakes are inversely associ- neutral, or negative associations between rates
ated with metabolic syndrome in adults. J Nutr 2016;​146:​81-9. of hip fracture and milk consumption,1,2 other
3. Vanderhout SM, Aglipay M, Torabi N, et al. Whole milk com-
population studies have consistently shown pos-
pared with reduced-fat milk and childhood overweight: a system-
atic review and meta-analysis. Am J Clin Nutr 2020;​111:​266-79. itive correlations between these rates and lati-
4. Kang K, Sotunde OF, Weiler HA. Effects of milk and milk- tude,3 even within a single country.4 This can be
product consumption on growth among children and adoles-
observed in a comparison of the original data by
cents aged 6-18 years: a meta-analysis of randomized controlled
trials. Adv Nutr 2019;​10:​250-61. Willett and Ludwig (Fig. 1A) with the latitude of
DOI: 10.1056/NEJMc2005220 the capital of each country (Fig. 1B). In this
analysis of rates of hip fracture, dairy consump-
tion is a surrogate for latitude (Fig. 1C). Thus,
To the Editor: Figure 1 of the review article by the authors’ comment that “low dairy consump-
Willett and Ludwig on the health effects of milk tion is clearly compatible with low rates of hip
consumption shows a graph of rates of hip frac- fracture” would be better stated as “Living in a
tures and the proportion of total energy intake country close to the equator is compatible with
from milk in 40 countries. The regression line low rates of hip fracture.”
indicates a positive correlation, suggesting a Richard B. Weinberg, M.D.
causal relationship. However, the authors caution
that “this correlation may not be causal and Wake Forest School of Medicine
Winston-Salem, NC
might be due to confounding by factors such as weinberg@​­wakehealth​.­edu

A B C
500 500 80
R2 =0.15 R2 =0.31 R2 =0.54
P=0.01 P<0.001 P<0.001
70

400 400
60
Hip Fracture/100,000 Persons/Yr

Hip Fracture/100,000 Persons/Yr

Absolute Latitude (deg)

50
300 300

40

200 200
30

20
100 100

10

0 0 0
0.00 0.05 0.10 0.15 0 20 40 60 80 0.00 0.05 0.10 0.15
Proportion of Total Energy Absolute Latitude (deg) Proportion of Total Energy
Intake from Milk Intake from Milk

Figure 1. Milk Consumption, Hip Fractures, and Latitudes of Capitals in 40 Countries.

Panel A shows the rates of hip fracture (per 100,000 persons per year) and milk consumption (as the proportion of
total energy intake) in 40 countries. Panel B shows the rates of hip fracture and the absolute latitude of the capital
of each of the 40 countries. Panel C shows the absolute latitude of each capital and milk consumption. Data on hip
fractures and milk consumption were obtained from the references in Figure 1 of the article by Willett and Ludwig.
Latitude data were obtained from Wikipedia (https://en​.­wikipedia​.­org/​­wiki/​­List_of_national_capitals_by_latitude).

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 Correspondence

No potential conflict of interest relevant to this letter was
reported.
1. Bian S, Hu J, Zhang K, Wang Y, Yu M, Ma J. Dairy product
consumption and risk of hip fracture: a systematic review and
meta-analysis. BMC Public Health 2018;​18:​165-81.
2. Matía-Martín P, Torrego-Ellacuría M, Larrad-Sainz A,
Fernández-Pérez C, Cuesta-Triana F, Rubio-Herrera MÁ. Effects
of milk and dairy products on the prevention of osteoporosis
and osteoporotic fractures in Europeans and Non-Hispanic
whites from North America: a systematic review and updated
meta-analysis. Adv Nutr 2019;​10:​Suppl_2:​S120-S143.
3. Johnell O, Borgstrom F, Jonsson B, Kanis J. Latitude, socio-
economic prosperity, mobile phones and hip fracture risk. Os-
teoporos Int 2007;​18:​333-7.
4. Odén A, Kanis JA, McCloskey EV, Johansson H. The effect of
latitude on the risk and seasonal variation in hip fracture in
Sweden. J Bone Miner Res 2014;​29:​2217-23.
DOI: 10.1056/NEJMc2005220
To the Editor: There are several relevant, recent
meta-analyses of studies of cardiovascular dis-
ease, including one by Soedamah-Muthu and de
Goede1 involving 15 cohort studies of the risk
of coronary heart disease and 17 cohort studies of
the risk of stroke, as well as a large multina-
tional cohort study by Dehghan et al.2 from 21
countries across five continents. Willett and Lud-
wig cited the latter study only for data on glyce-
mic load. Both of these studies showed a neutral
or beneficial association of milk consumption with
reductions in the risk of cardiovascular disease.
Willett and Ludwig cited a study by Chen et al.3
that involved dairy fat (not food) and only three
cohorts in the United States. Willett and Ludwig
do not mention the report by the National Os-
teoporosis Foundation4 that emphasized high-
quality evidence confirming that the peripubertal
years are critical for bone accretion, with posi-
tive effects of calcium intake, as well as good
evidence of a role of dairy consumption in bone
development.
The review article by Willett and Ludwig is
focused primarily on the population in the United
States. I am concerned that this article may dis-
courage milk consumption in many populations José M. Belizán, M.D., Ph.D.
that would benefit substantially from it. Gabriela Cormick, M.Sc., Ph.D.
D. Ian Givens, Ph.D., R.Nutr. Institute for Clinical Effectiveness and Health Policy
University of Reading
Reading, United Kingdom
d​.­i​.­givens@​­reading​.­ac​.­uk
Dr. Givens reports receiving travel expenses and lecture
honoraria from the “Milk, Nutritious by Nature” initiative of the
European Milk Forum and the United Kingdom Dairy Councils.
No other potential conflict of interest relevant to this letter was
reported.
1. Soedamah-Muthu SS, de Goede J. Dairy consumption and
cardiometabolic diseases: systematic review and updated meta-
analyses of prospective cohort studies. Curr Nutr Rep 2018;​7:​
171-82.
2. Dehghan M, Mente A, Rangarajan S, et al. Association of
dairy intake with cardiovascular disease and mortality in 21
countries from five continents (PURE): a prospective cohort
study. Lancet 2018;​392:​2288-97.
3. Chen M, Li Y, Sun Q, et al. Dairy fat and risk of cardiovascu-
lar disease in 3 cohorts of US adults. Am J Clin Nutr 2016;​104:​
1209-17.
4. Weaver CM, Gordon CM, Janz KF, et al. The National Osteo-
porosis Foundation’s position statement on peak bone mass de-
velopment and lifestyle factors: a systematic review and imple-
mentation recommendations. Osteoporos Int 2016;​27:​1281-386.
DOI: 10.1056/NEJMc2005220
To the Editor: The article by Willett and Lud-
wig, which focused mainly on recommendations
for the intake of milk and dairy products in the
United States, concludes with the potentially
negative consequences of consumption of dairy
foods. We are concerned that this message could
affect the intake of dairy foods in populations in
low- and middle-income countries that have very
low calcium intakes.1,2 Data from randomized,
controlled trials have shown that the attainment
of adequate calcium intake in populations with
low calcium intake decreases the incidence of hy-
pertensive disorders of pregnancy.3 An adequate
calcium intake is also associated with decreased
blood pressure, prevention of osteoporosis and
colorectal adenomas, decreased cholesterol levels,
and decreased blood pressure in offspring.3
Achieving an adequate calcium intake through
sources proposed by the authors (e.g., kale,
broccoli, tofu, nuts, beans, and fortified orange
juice) is not feasible for populations in low- and
middle-income countries and could have serious
health and economic implications. The intake of
milk and dairy products should not be discour-
aged globally, and considerations in this article
should be restricted to populations with a high
calcium intake.
Buenos Aires, Argentina
gabmick@​­yahoo​.­co​.­uk
No potential conflict of interest relevant to this letter was
reported.
1. Cormick G, Betrán AP, Romero IB, et al. Global inequities in
dietary calcium intake during pregnancy: a systematic review
and meta-analysis. BJOG 2018;​126:​444-56.

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 The n e w e ng l a n d j o u r na l of m e dic i n e

2. Balk EM, Adam GP, Langberg VN, et al. Global dietary cal- take of 400 to 500 mg of calcium per day; we
cium intake among adults: a systematic review. Osteoporos Int
concur that this may be an effective strategy in
2017;​28:​3315-24.
3. Cormick G, Belizán JM. Calcium intake and health. Nutri- some contexts.
ents 2019;​11:​1606. The updated meta-analysis by Soedamah-
DOI: 10.1056/NEJMc2005220 Muthu and de Goede4 confirmed their previous
2017 meta-analysis that we cited showing null or
The authors reply: Astrup, and Vanderhout weak inverse associations between consumption
and Maguire, argue that we underrepresented of dairy food and the rate of death from cardio-
the benefits of milk with respect to obesity. How- vascular causes. The Prospective Urban Rural
ever, their citations substantiate a minimal effect Epidemiology (PURE) study of dairy intake and
on adiposity. In a meta-analysis of randomized, cardiovascular disease and mortality in 21 coun-
controlled trials, Chen et al.1 reported a “modest” tries had far fewer cases of cardiovascular dis-
short-term reduction in body fat with dairy con- ease than these meta-analyses. Unfortunately, in
sumption, but they reported that their finding all these meta-analyses, dairy foods were simply
“does not support the beneficial effect of increas- compared with the rest of the diet. As shown in
ing dairy consumption on body weight and fat Figure 2 of our article and as described in an
loss in long-term studies or studies without en- updated analysis,5 consumption of milk was as-
ergy restriction.” Similarly, Kang et al.2 reported sociated with lower mortality than consumption
that dairy consumption increased body weight of processed red meat, and it was associated with
and lean mass, with “no significant changes in higher mortality than consumption of plant-
fat mass . . . or waist circumference in the in- based sources of protein. Thus, simple null asso-
tervention groups compared with the control ciations can obscure effects of important dietary
groups.” Nevertheless, we recognized that the ef- alternatives.
fects of milk on health would probably be modi- Walter Willett, M.D., Dr.P.H.
fied by baseline diet quality and nutrition status, Harvard T.H. Chan School of Public Health
consistent with the substantial heterogeneity in Boston, MA
these meta-analyses. wwillett@​­hsph​.­harvard​.­edu
Weinberg suggests that latitude may confound David S. Ludwig, M.D., Ph.D.
the positive ecologic association between milk Boston Children’s Hospital
consumption and fracture risk, a long-standing Boston, MA
enigma. We agree and mentioned vitamin D Since publication of their article, the authors report no fur-
status and ethnicity as variables that may plausi- ther potential conflict of interest.
bly mediate the relationship with latitude. Be- 1. Chen M, Pan A, Malik VS, Hu FB. Effects of dairy intake on
cause of a potential for confounding, we also body weight and fat: a meta-analysis of randomized controlled
considered other types of studies, which overall trials. Am J Clin Nutr 2012;​96:​735-47.
do not support a benefit of high dairy intake for 2. Kang K, Sotunde OF, Weiler HA. Effects of milk and milk-
product consumption on growth among children and adoles-
prevention of fractures. As for the studies men- cents aged 6-18 years: a meta-analysis of randomized controlled
tioned by Givens, we cited a more recent ran- trials. Adv Nutr 2019;​10:​250-61.
domized trial showing no benefit of added milk 3. Vogel KA, Martin BR, McCabe LD, et al. The effect of dairy
intake on bone mass and body composition in early pubertal
intake for bone health.3 girls and boys: a randomized controlled trial. Am J Clin Nutr
We agree with Belizán and Cormick about the 2017;​105:​1214-29.
4. Soedamah-Muthu SS, de Goede J. Dairy consumption and
effects on low- and middle-income countries, cardiometabolic diseases: systematic review and updated meta-
and we stated that dairy consumption can con- analyses of prospective cohort studies. Curr Nutr Rep 2018;​7:​
tribute to nutrition quality, especially for chil- 171-82.
Ding M, Li J, Qi L, et al. Associations of dairy intake with
dren. Notably, the benefits they describe are 5. risk of mortality in women and men: three prospective cohort
based largely on randomized trials of calcium studies. BMJ 2019;​367:​l6204.
supplements, not milk, and they suggest the use DOI: 10.1056/NEJMc2005220
of fortified foods or beverages to achieve an in- Correspondence Copyright © 2020 Massachusetts Medical Society.

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