 Ricardo thank you and I want to thank Danon and the other supporters and organizers of the symposium I guess you tried to set me up for something we'll see a number of you in here heard me speak on this we gotta find the right talk it's someplace I'll just use yours I think it's there is that it no no there is while Andrew's doing that I'm gonna at the end show him historically that there were some people in the Midwest the United States that consumed more yogurt than you could ever imagine this is a topic that actually here are my disclosures are pretty minimal other than just being an iconic last Robert Haney who's known to many of you in his room and I wrote this paper back in 2005 and because of time you can go read the methodology here and see how I come up with some of the numbers this is a difficult task to try to put a dollar figure or Euro figure on what the benefits to either the US or worldwide might be if we could improve dairy product intake Andrew set us up it's clear that some societies are more successful at this others are not there's biological reasons why that may not be the case there's also economic reasons availability the list goes on but where we have solid data which is what I'm gonna try to share with you of what the potential could be I think we need to stop and pay attention to this it's no secret particularly in this state of Massachusetts that health care costs are out of control we have a situation here a unique one actually in Oregon where I reside that's different but in both cases we're trying to get a cap on how we're spending our money and I think one of the challenges that the nutrition community faces is standing up and trying to inform the public our leaders that we have a strategy if we could just implement it worldwide that could lead to dramatic health care savings I don't know what the real number is but I can tell you the numbers big if we could do it so my story starts here what I'm gonna try to do is give you just a feel for what a quality diet is I don't think there's a lot of debate about this with exception of Walt's view on dairy foods I'd like to just show examples from the literature when you describe a diet this high quality dairy product just sticks out in the description it's a very consistent and that actually Andrew's right you have to dig to try to find specific examples but because of the way new data is being published with longitudinal studies that are fairly large databases imperfect observational studies there's no doubt about it you can actually show yogurt specifically within the dairy category as being tied to a health benefit or outcome and from that I'm going to use the process and we're going to go through this very quickly and we'll discuss this in much greater detail with Andres and myself in the workshop after this session how do you really come up with a number that you could believe and I don't think it's possible to get a firm rock solid number I think it is possible to say we have an opportunity here to dramatically improve health care at a remarkably reduced price so there is a member of the audience who was a partner in crime with me back in 1984 when we published what I think still remains the largest nutrition paper in the journal science which doesn't usually publish those kinds of papers where we looked at the first end Hain study Victor Fulgoni took a clue from that early in his career and kept chasing these numbers through one iteration after another and when we looked at blood pressure in America you could do a multivariate analysis of N. Haynes and pick out the food groups that would best predict your blood pressure status that is a good one in America and here's the table it's an exact reproduction of table three in that article and it is the original description of the dash diet dairy products fruits and vegetables non-sugar beverages keep us think about this list and then the publications that have come out 30 years later fats and oils and essentially products are protein rich and at the bottom is the famous dessert impact that was first brought out in a cardio trial where as a reviewer I said to the editor please have these authors have the political courage to label it ice cream but they didn't they called it frozen dairy-based dessert and if you just went back to that science paper the benefit of being on a dairy rich fruit and vegetable rich diet essentially a high mineral high protein diet you saw a 60% reduction in the incidence or likelihood of being hypertensive in America and about a 60% improvement in weight and by the way this was the original description of dairy's relationship to potentially improve weight control and at the end of our science paper this is what we concluded Debbie who's in the front of this audience may remember reading this it's not a very exciting conclusion but that's the way nutrition is sometimes and it says you know you need to eat a balanced diet and that is appropriate for your level of activity when interviewed on CBS morning news at the time of this publication the anchor said to me you know Dr. McCarran this is not very exciting and and I had a short answer I'm sorry and it is on tape so let's just look at some examples if we had a you know more time I had more time there are those of you in the audience know that there are many examples of this so here is the cancer study which is actually one of the initial you know reasonable prospective assessments of diet quality and health risk particularly cancer and cardiovascular mortality this is an example that if you were in a fourth quartile as opposed to the first quartile of a healthy diet your all cause mortality was 35% less than if you didn't eat as good a diet the worst one being the low quality when you look at what those authors concluded a quality diet was it's what I said it's the obvious fruits and vegetables whole grains low-fat dairy and lean meats and surprisingly they said it's a good idea to eat this from foods as opposed to supplements and what not and they said this represents a practical recommendation it's almost as exciting as our conclusion you know 20 years before in science you can go look at you know what is the largest cohort that's in the medical nutritional literature which is the NIH AARP longitudinal study and this is a little over 10 years the numbers are small on the screen and I apologize for it but what I've done is not try to distill I've just put the tables as a peer in the literature and if you look at it again both in men and women there's about a 25% reduction in all cause mortality the better your diet I don't know if a drug that's out on the market they could do that and if you look within the tables and descriptions in that paper fruits and vegetables low-fat dairy whole grains and lean meats and poultry now I have to be honest the dairy is always labeled low fat but I'm not sure but if you start taking that data apart you can justify that separation I'll be blunt and iconoclastic apparently for Lindsay's sake and say those are political words they're not scientific words so here's another way of looking at what if what if you what if you have a lousy dietary pattern work in the Lancet in 2005 and again many of you may be familiar with this and an interesting way of looking at it and that they took people who had little fast food or had more fast food and how they changed their intake of fast food and what happened to their essentially their insulin regulation or glucose metabolism and if over the period of observation you stayed with little fast food and you didn't change your change in your insulin regulation and glucose metabolism didn't change if you ate a lot of fast food at the beginning and you ate even more at the end you didn't look quite as good at the end and the same thing applied for weight gain over the period of observation in this study and it's a 15-year period and it's a you know interesting way of looking at it if you then look at what they said increased or decreased if you eat fast foods you know it's not gonna be surprising if you ate fast foods you decided to eat more fast foods your fruits and vegetables went down your whole grains went down your fiber went down and your dairy went down you increased your soda you increased your alcohol you had more fat and you ate more refined grains so it's another way of sort trying to position on the grid where dairy fits into a healthy diet and that it has metabolic or health consequences there's a famous statement from the past presidential candidate who's now a radio and TV host who said you know if it comes through the window of a car don't eat it another way of looking at this is the longitudinal study of what predicts weight gain over the long haul and this is work out of a school of public health here and we're gonna come back to this but the foods that predicted the weight gain were potato chips that's bad news for a lot of people potatoes sugar sweetened beverages red meats sweets and desserts and 100% fruges those that were associated with keeping weight normal were actually improving top of the list and you'll see the actual graph was yogurt and this is one of the studies that begins to specifically identify the yogurt component of the dairy diet as being impactful perhaps over and above other dairy foods and then again fruits whole grains nuts vegetables and milk what about cardiovascular disease hypertension stroke heart attacks are routinely identified we talked a little bit about this by the WHO is the big burden of disease and disease costs in this country this is another way of picking apart observational data and people who do or do not have a cardiovascular event in this case stroke and is there a difference in the way they consume in this case beverages that may identify some benefit of dairy products so this is stroke risk if the line doesn't cross the the zero point which is true the lower two categories and almost true here if you substitute tea caffeinated beverages for a sugar sweetened or non sugar sweetened beverage and then with skin milk you see a substantial difference in your risk of stroke we tend to think of sugar sweetened beverages as worse than non sugar sweetened beverages and I don't I think that's a debate that needs to keep going because the data looks like anything is better than a soda whatever is in the soda and water is neutral which makes sense and tea coffee fluid dairy products are good to substitute so stop worrying when you have that third cup of coffee in the morning you're just going to be more alert to live longer apparently so here's another way you're looking at low calorie sodas as opposed to sugar sweetened and here clearly if you had milk had a caffeine drink your risk of stroke goes down compared to drinking a diet soda or diet liquid beverage and if you call through all the longitudinal studies that now are appearing at a fairly rapid rate in the literature because this is data in a lot of cases that was collected initially where the studies were started maybe even back in the 19 late 1980s so it's understandable that we're now just following seeing 10 15 20 year follow-up data it's not much different than what the Ann Haines data told us back in 1984 you need to have dairy foods fruits and vegetables we can argue which is more important I haven't figured that one out whole grains I don't think there's any debate about it how much whole grains your intestine will tell you if it's maybe too much a handful of nuts or more every day intrigued by Rick Mattis's work out of Purdue that Connie knows that you can eat nuts if he's right until your nuts and you burn more calories eating a nuts and digest them then you can and get the nutrients then the calories you consume it almost sounds like nuts or the ultimate low-fat or weight-reducing food and we need protein rich foods there's no question about the evolution of societies have been based upon the ability to acquire these sources of protein and coffee tea water are good for you I've shown you snippets and some of this Andrew covered there are relationships to obesity our science paper there's a graph I didn't show it that we may remember it that showed that if you were in a category of a higher dairy consumer and Haines one there is a dramatic difference in your BMI in the United States and that led to a lot of the work that was subsequently done by other investigators who on the average have forgotten where the original observation was made cardiovascular disease the focus of our group many years ago was to bring out the notion that there was a relationship between electrolyte mineral content of dairy foods and a reduction in blood pressure which certainly is one of the factors that lies the heart of cardiovascular disease diabetes show a couple examples because I'm not done here cancer of course the ongoing discussion about how much calcium and vitamin D you really need I think Bob Haney wrote one of the great lines in his New England Journal article or editorial last summer when he said more ink has been spilled on this issue with the exception of the sodium debate in the history of medical research you know how much calcium how much vitamin D for bone health renal failure it's an interesting story I'm a nephrologist and I think we're going to see over the next decade some transitions and are thinking about the relationship of diet quality to the evolution of some chronic kidney diseases and that the community my community has probably managed some of these patients in a reverse fashion that they should be managed in terms of slowing the progression of the disease and actually probably the biggest opportunity it's out there is how we use improved nutrition during gestation maternal and child health development I think again the points Andrew made about how the infant evolves has a mineral rich milk rich diet initially and then makes that transformation the benefits as originally brought out by David Barker when he was still at Southampton about fetal programming another issue that was has been at various times hotly debated seems to be very reproducible throughout databases around the world that if you're born bigger your mother's healthier you live longer you have less burden of chronic diseases so focus there in our societies of nutrition may have the ultimate long-term benefits in terms of not only health care costs but productivity and contributions to society's advancement the problem is if you look at the NHANES databases and Victor would be much better to speak to us but in general all this effort if you look at the decade of the mid 80s to mid 90s compared to the mid 90s to mid 2000 we're actually losing ground in terms of the quality of the American diet and I attribute this to the ability of various elements it includes incident experts who appear to show up on TV and radio all the time who've turned eating into what I call near-death experience we have created an atmosphere around our eating that scares people and they think they have to do less cut this out cut that out and we're spending all this money on biomedical research and we're losing ground if the leadership and this will be dangerous this is what dr. Allen predicted if these people in Washington work for a private company they would have been fired 20 times over because we're not getting to where we need to get to and a lot of that I think is our burden because we're not communicating what we need to not just to our colleagues but to society at large so dairy foods are a surrogate for diet quality and health outcomes it pops up in many of the databases with a wide range of reduction of disease risk how tight the association is how reproducible we can discuss under certain scenarios but it appears to be a very consistent finding and if you improve dairy intake you appear to have a major reduction of disease burden dairy again as Andrew pointed out right at the beginning and we're going to talk about in a subsequent lecture it's a very dense nutrient package it's relatively inexpensive and particularly with yogurt it's something that you could maintain and have available virtually worldwide independent of things like refrigeration and whatnot and there's a way to follow this if there's a paper hidden in the journal of nutrition that I still think is one of the more important simple observations if you just follow urinary potassium intake which is a marker of dairy you can predict whether or not somebody is on a quality diet so we're going to finish up by just showing that the risk of stroke goes down with dairy you can then dig into stroke and a very unusual study looking at intimal thickening and its relations specifically to yogurt consumption and the references on here it just doesn't show on the slide so you either want to be in a moderate to high intake category of yogurt to have less intimal thickening in individuals in this case I believe it was mostly women who are at risk of stroke and here this is a structural change that you can at least associate with yogurt intake specifically overweight again this is a cardiac study which showed that it literally a dose response between little a little more a moderate amount a little more than moderate and a high intake of dairy and a stepwise reduction in your risk of obesity and then you dig in to the Harvard data which I talked about earlier and this is an example where the literature unequivocally identifies of the foods that you would have in your diet to improve weight management milk is there other dairy foods there but yogurt just sticks out above just about anything else incense of glucose and tolerance again a dose response from the cardio trial just as one example that data we're going to continue to hear more about is that longitude and assessment is reported further so if you have more dairy you have less glucose and tolerance you can go in and look at people who say they're lactose intolerant versus those who say they can eat and do eat lactose containing dairy products and you get numbers they're very similar to what we said in science back in 1984 those people who are able think they're able to have regular dairy foods have a 40% reduction in their risk tied to their description of whether or not they're lactose intolerant or not which Dennis would tell you most of them are not but they think they are and they're avoiding dairy products those people compared to those who are consuming dairy and yogurt have a substantially increased risk of both hypertension and diabetes we talked in the previous about the relationship of cancer here is a paper several years ago showing roughly a 10% reduction in all cancers based upon calcium intake as a surrogate for dairy and then you can go into this AJCN paper in 2008 where they actually looked at bladder cancer and culture milk and yogurt and could in this case again it's an example where you can find data within dairy that pinpoints yogurt's impact and it's not subtle I mean I don't know a drug that's been shown to have that impact on cancer risk colon cancer well accepted and here's the general effect it's interesting folks in Bob Haney's category would like the fact that it seems to peg at least 1400 milligrams of calcium a day unless you're at Harvard School of Public Health and if you look specifically that this International Journal of Cancer did at where yogurt impacts that it's you know a fairly remarkable 35% reduction and here's some of the birth weight data this is increasing birth weight which is associated with long-term healthier more productive intellectually engaging and it's actually protein intake from dairy products it's associated with this in its very large database that's in from AJCN in 2007 and then specifically that was dairy protein there's this paper from the European Journal of Clinical Nutrition last year that identified that probiotics yogurt were associated with a improved or reduced risk of gestational diabetes which is a hallmark of a bad outcome of pregnancy so probiotics yogurts were improving or reducing the risk of gestational diabetes so we know there's a variety of benefits this is a partial list the data is pretty consistent in medical literature there's a lot of things at least intestinally that yogurt and probiotic dairy products provide they cover some pretty common problems in society and they're fairly expensive ones and consistent use of probiotic dairy foods yogurt would appear to impact so if you went into the medical literature in the or the government literature a year ago roughly 18 months ago and looked at the health care costs and this is a very dicey proposition our country no country really knows what it's spending on certain diseases and that's the problem of building an economic model because you can't be certain what the base cost of a disease is but as best as you can determine from sources by searching the internet these are the costs based really on 2009 2010 data what given the total cost and what you know the data says you can do with blood pressure ischemia stroke and you can read our original paper we use the same conservative assumptions so these are numbers that are roughly 25% of what you could claim was the benefit and these are the savings that if the United States just got 25% of the population to increase their dairy intake that over the even the first year because some of these benefits are seen immediately particularly with issues like blood pressure and diabetes and the end of the list cancers osteoporosis they're big numbers this adds up to a big number and it's almost so big you look at it and you say this is in the fairytale category but I don't think it is this country and it was highlighted in a Kaiser study from the Kaiser Family Foundation report yesterday we're well into the trillions of health care costs in this country this is not a ridiculous figure for a year when you consider that and if you reasonably projected given the fact that some of these effects take years to kick in you could make a reasonable estimate that in the United States in five years we would save the amount of money that the Congress is trying to find in our budget I just think we need to put our congressman on a yogurt diet so it's essential yogurts why the nutritional profile the unique probiotic characteristics that go back thousands of years and it then provides a way for the lactose intolerant to consume it's available it's portable wide range of flavors it fits in with the fruit and whole grain type issues that you can deal with here Andrew is the example of overconsumption I show this with some trepidation but it's an exact quote from JAMA from two years ago about Dr. Kellogg who founded a cereal company in Battle Creek and I'll let you read what Dr. Kellogg used to do to his patients in Battle Creek it sort of raises the question of maybe it doesn't matter how you ingest it it's all Greek to me so but the study of medicine is still the study of individual patients this woman who was visited by mr. Obama should have been the poster child for nutrition and health in America although her diet doesn't fit with what the chef of the White House is promoting in the United States but she lived pretty long and she did really well eating fried chicken crispy bacon and yes ice cream thank you questions for Dr. McCarron microphone is here can you introduce yourself and hi I'm Barbara rolls from Penn State there are a lot of excellent randomized clinical trials such as dash and they look at dairy do you think there's a possibility to go back and separate out yogurt different types of dairy products and tease out benefits I I would have to believe that Bill Volmer that the Kaiser Center for Health Research in my hometown has that data and whether the component of yogurt had some type of a bigger impact the problem there is it's a very small sample it's a very short duration but it's a clue and it could be helpful I think maybe we ought to try to explore what RCT data are out there that could have this kind of secondary analysis applied Andrew so my question is kind of related you've made some some very strong claims David and he's shut me up but I also set you up by saying that these analyses are very complicated and I don't believe I heard you use the word confounding in your talk so I think in fairness I need to press you especially with a lot of young people in the audience I need to press you to address which I'm sure you have done at great length but address for us the issue of how you deal with potential residual confounding in such associations so I you know that's it's the problem that nutritional research can almost never solve because foods are what we eat not nutrients those foods are made up of a variety of different nutrients and the different foods likewise and you get into a statistical canubrium that is almost impossible to tease apart that said and I don't mean to set Andres up but that's what we're gonna talk about in a workshop is okay you have these observations I guess I'm reminded as somebody who was a faculty colleague at Oregon back around a time the science our first science paper came out and we were constantly hounded with what is it that makes the blood pressure go down and a lot of work had was done has done been done it's still being done to try to figure that out but this individual who was not a nutritionist but eventually became the president of the American Society of Nephrology so it was not totally without its ruble Cortex said what's it matter if these foods help you then let's make sure we emphasize those foods but your point is the problem that we're always going to have and we have to be careful what I know I feel is we're not improving the quality of the diet worldwide it's going the wrong direction and if we could be better at that we would be extending life on fewer meds fewer hospitalizations and costs would go down it probably boils down to the components that appear to keep coming out of these surveys and statistically to come up with a number it's impossible next question please yeah I Dan Marence from Georgetown University and just to get to that it's a problem we have but we can address that we can do randomized control trials I mean I feel like I could have replaced every slide you had with poverty or socioeconomic status and I would have almost had the same exact outcome but really my question is randomized controlled trials to much of my surprise the the best randomized controlled trials we have although there's short term so the Atkins diet is the best for lipids for blood pressure for weight loss and where does that on the low fat low the dairy product you're also re randomized controlled trials you can put not people like me but other people who have been engaged in these types of debates who will argue with you that maybe in the area of nutrition randomized controlled trials aren't the best partly because of the duration and whatnot but there is no question that to the limited extent that some of these diet patterns have been tested in a randomized controlled trial you are better off with what has generally been considered the Atkins type protocol that doesn't mean it's the optimal diet it just means compared to some other potentially bad diet it looks better so okay people are standing in the back there's still seats over here if you want to come up Moggabark or Sheffield I was very interested in your comment that urinary potassium was a good biomarker of dairy intake and perhaps to corroborate some of the data were coming from these observational studies that hide dairy as beneficial we should be supporting those data with measures of urinary potassium yeah we evolved to excrete two nutrients every day almost in totality and their sodium and potassium and they are to the nutrients that on the bad and a good we've debated ad nauseam hopefully some clarity as soon arrive on the sodium issue the study I talked about was done by sandy Logan and Andrew Melton at Toronto and the Mount Sinai research group there and they had good data on what people were eating and they showed very nice correlations between improving diet quality and simple marker as urinary potassium that's something a nutritionist or a physician could use and it's inexpensive and to say you're making progress you're not making progress thank you before we close I have a question as chairman how about your comparisons between high and low fat and the emerging data that high fat is potentially even better than low fat your I think you asked me that question because you thought I'd be dumb enough to answer it but listen dietary fat is a political issue as much as it is a scientific issue and that's unfortunate we've had particularly regulatory agencies and advocacy groups come down very strongly on the side of certain aspects of the human diet those positions are thought to be non conflicted but I would argue that the position of a governmental agency or an advocacy group such as American Heart or whatnot is every bit as conflicted as a corporate position is because they put a stake in a ground and they've said it's got to be low fat it's got to be low sodium and when the data begins to shift on you what do you do you go eat yogurt I'd like to make a point though relative to WHO has already a second note and in fact steric acid is a saturated fat but is considered neutral from a certain cardiovascular risk so again thank everybody and I know we've got to move on okay very good so thank you