 Thank you, Johanna. Johanna was on a Dietary Guidelines Committee before me, so she can make a personal statement about the amount of work, but it's a highlight of your career to be able to serve in this impactful way. Because I was on the 2005 Dietary Guidelines Committee for America, that's going to largely influence the proportion of the emphasis of my talk, partly because I know it the best, but partly because that's when three cups of milk per day above age nine were set. In the 2010 Dietary Guidelines Committee kept those same recommendations, so that kind of makes me think the evidence that was in place for the 2005 wasn't refuted or wasn't sufficient to alter their recommendations. Here's my disclosures. So the 2010 Dietary Guidelines for Americans shows shortfall food groups that relate to shortfall nutrients. So if you consider the shortfall food groups as vegetables, fruits, whole grains, fluid milk and milk products and oils, you see the corresponding nutrients that seem to be in short supply in a large majority of the American diets. And the four shortfall nutrients that they identified for almost everyone was fiber, and then three that come from fluid milk and dairy products, calcium, potassium, and vitamin D. And then the other ones are for selected populations or more marginally, the pleat. But it's not just the U.S. that recommends about three servings of dairy per day. All of these countries recommend between two and three servings a day. So they come to their own conclusions about the role and importance of dairy products in the diet of their own individuals. Now, mostly dairy recommendations are set based on bone health. And I remind you that bone health is a lifelong concern. We're especially interested as you develop peak bone mass early in life because you don't have a chance to gain bone later. Once you've achieved your peak by the end of late adolescence, then you are trying desperately to choose lifestyle choices to hold on to the bone the rest of your life so that you don't get in the fracture risk zone. Now, the 2010 Dietary Guidelines Committee, if you look in the report, concluded there's a moderately strong level of evidence for the relationship of dairy in the diet to bone growth early in life. I'll review a little bit of the kinds of evidence that they had that can conclude that. But they found on the other end of life it's a much more mixed bag of evidence on this relationship of dairy to holding on to bone later in life. And more studies are needed as, as always, what a researcher says. The majority of Americans are falling short of these dairy recommendations of three cups of milk or the equivalent of day. And you can see the median milk equivalent intakes in the U.S. on the lower left. So the only group that gets close to the recommended intake are adolescent boys. And I remember my teenage boys would go to the refrigerator not bother with a glass of milk, you know, just getting a lot of calories and milk was a very convenient food for them. But all the other age groups are pretty far from the recommended intakes of three cups a day. And the most concerning, of course, is adolescent girls who tend to build a lower peak bone mass than boys and puts them more at risk for fractures. So 80% of women or hip fractures are in women instead of men. And they're only getting half of what they're recommended intakes are at those critical years of the window of opportunity of growth. The dietary patterns in the U.S. are based on two procedures. One is food modeling to meet the DRIs. So they don't question what the recommended intakes of nutrients are. They take what the IOM process produced for all the different individual nutrients and then they try to say what food patterns are recommended to get those nutrients. So it's not about challenging the calcium needs or the vitamin D needs or the potassium needs. It's what food patterns do we need to have to acquire all those nutrient needs. So they start with the basic food basket in the U.S. They know from food composition or food intake data how many servings of broccoli to our age and sex categories consume or how many cups of milk and they start with that. And then they say what minimal amount of changes do we need to make to achieve the DRIs. And that's what they do to get to the basic food patterns. But a secondary process is what's the evidence of the relationship of the food intake like in a dose response manner. What is the relationship of one serving, two servings, three servings of milk or the equivalence on some outcome measure like bone mineral density or whatever the outcome measure is. And as with the evidence-based approach today, randomized controlled trials are the priority level of evidence. So if you have a favorite study in your head that isn't a randomized controlled trial that shows something different than what the conclusions are, it'll never replace a randomized controlled trial. So these three cups of low-fat milk or a equivalent, what they provide in terms of nutrients are essentially all of the calcium that is recommended, all the phosphorus, half of the protein and it's a good quality of protein, a third of the riboflavin, 28% of the potassium. And I want to tell you, we got to three cups of milk a day in most population groups in the dietary guidelines because of potassium. You think it's because of calcium, but we really had reached what we needed to reach in terms of calcium with other food patterns that include two servings a day. But during the time we were meeting to set the 2005 dietary guidelines, they came out with the new RDAs for potassium, which was an AI. We couldn't get to even close, you know, three quarters of the intake of potassium recommendation unless we added that third serving of dairy a day. So potassium really drove the complete remodeling to get up to three servings of milk a day or the equivalent. Those three cups also provide 25% of the magnesium and many other nutrients. And here's a list of most of the nutrients that were identified as providing at least 10% of the recommended intake of those nutrients. So what a rich package of nutrients that dairy products provide to the consumer. So when we tried to identify alternative sources for those who avoid milk or dairy products in their diet, the closest alternative that we identified was calcium fortified soy milk. So a three cup comparison, if you see cow's milk on the left, exactly quantitatively how many milligrams or grams of each of these key nutrients that milk provides, then I illustrate the difference that three cups of calcium fortified soy milk can provide on the right compared to the milk on the left. So it provides even a little bit more calcium because it's added, the natural soy beverage doesn't have that much calcium. So it has to be calcium fortified. And for quite a while, it was believed that that calcium from the soy beverage was much poorer absorbed. And then we did a study where we worked with a manufacturer that makes the most popular form of soy milk in our country that uses calcium carbonate and we used stabilized hopes and went through the manufacturing process and actually measured calcium absorption from soy milk processed as it would be drunk compared to cow's milk. And if it was made with calcium carbonate, it was equivalent. But if it was made with tricalcium phosphate, like some of the calcified forms where it was significantly less, although still not that bad. And as a result of that study, USDA now allows calcium fortified soy milk as an alternative calcium source in school lunches in the U.S. So calcium would be okay, a little bit less of phosphorus, not a problem because most people get enough phosphorus, a little bit less protein. But look at how much less potassium, which is why we got to three cups of dairy a day in the first place. Quite a bit less potassium. Okay on magnesium and riboflavin and less vitamin D, which fortified milk is the major source of vitamin D in our diet in this country. So that's a little bit of a concern as well. So there are alternative sources for milk avoiders for this package of nutrients, but you have to really be conscientious. You have to get calcium fortified beverages mostly. Here is the food modeling system showing you for an example in females age 19 to 50 years old, how much of the recommendation of these three shortfall nutrients, calcium potassium and magnesium, you get with milk products in the diet, you meet the calcium requirements and magnesium requirements, you're still short on potassium, but look at what happens without the milk products. You're way short on these three essential nutrients. And in Haines shows Americans just don't choose the alternatives to get the same package of nutrients, even if there's a few out there that you can do, and supplements don't fill the whole gap either. Specifically for children, two to eight years old on the left and nine to 18 year olds on the right, Teresa Nicholas did an analysis of in Haines and showed in the darker bars if people were consuming almost the recommendations somewhere between two and a half and three and a half servings a day versus the lighter bars with one or less fewer servings a day, what the difference is in meeting the calcium, potassium and magnesium requirements. It's just very remarkable if you have dairy in your diet versus you don't for meeting just the math of meeting the nutrients. And so her conclusions were fewer than 3% of the US population meets potassium recommendations. 55% did not meet even the estimated average requirement for magnesium. 30% of those aged two years and older met the calcium recommendation and were more likely to meet it if they had dairy in their diet than non-dairy sources. So dairy products are the best and most economical source of the limiting nutrients. They are also a real big marker of nutrients. And you heard this several times this morning and I'm going to show you a couple of studies exemplifying that and supplements don't totally fill the gap. People aren't choosing them. So let's start with calcium, which is why a lot of countries say two to three servings is their dietary recommendations for dairy. So the requirements from the IOM in North America for the different age groups are on the left. You can get it from foods, fortified foods and supplements as we've mentioned. And the reality is with all those choices four out of ten Americans don't consume enough calcium. And here's the age and gender distribution of that. So the first study that I want to tell you about on calcium being a marker of diet quality and by inference milk because so much of the calcium in the diet comes from milk, it is a little bit older study now but it's real simple. Now I loved Victor Fogoni's talk this morning where you could do weighted nutrient comparisons with regression analysis and that's very sophisticated and I really hope the future offers that for us then. So I'm going to show you two simpler studies. It's easier to explain and to visualize but it doesn't weight the nutrients. So Bob Heaney loaned me these slides to show you of his study in 272 healthy Caucasian premenopausal women who did seven day diet records. And the way this dietary guidance assessment works is you have nine nutrients as listed on the bottom and you either give them a one point or a zero point with a cutoff of like 67% of the recommended intake at the time. So the maximum score you can get is nine if you achieve two thirds or more of the recommendation for all of those. Calcium came mainly from dairy foods in this cohort that he looked at and he kind of arbitrarily said if scores were four or below it represents a poor diet if they're above four an adequate diet. So on the bottom left is a little box where he's looking at the people who had a calcium score of zero meaning they didn't get it even two thirds of the recommended intake of calcium. There were 151 of those who had a calcium score of zero. So here's the nine nutrient or the eight other nutrients besides calcium across the x-axis to show you kind of the distribution. So remember four and below is a poor diet and above four is an adequate diet. Contrast the distribution of scores from the ones who had calcium score of zero with those who had a calcium score of one which were 121 women. It really is good to a more adequate diet than a poor diet if they had a calcium marker score. So it's a marker of good nutrition. So conclusions from that study while only 10 percent of women with adequate calcium intakes had poor diets overall a single serving of milk or yogurt would have converted most of the poor diets to adequate. Now there's a brand new study specifically on yogurt so I was thrilled to finally have a study where they really looked at yogurt and this is from the Framingham heart study offspring in 6500 plus people where they divided a man to consumers of yogurt or non-consumers. 64 percent of the women and 41 percent of the men in this cohort were consumers and several of the nutrients that I listed from their paper showing the percent less than the estimated average requirement on the left in consumers versus non-consumers on the right. So you see for all of these nutrients riboflavin, vitamin b12, calcium, magnesium and zinc the percent that were below the estimated average requirement really decreased significantly if they were consumers versus non-consumers and the percent above the adequate intake was improved. You have to do that for potassium and fiber because they don't have any AR and the percent really improved for potassium and fiber if they were yogurt consumers. So it was really nice to have a study specifically looking at yogurt. I want to discuss factors influencing bioavailability of nutrients and I only have time to talk about calcium but this could apply to many of the nutrients that would be provided in dairy products. Life stage makes a difference. The loaded anyone meal, the status, the habitual intake, presence of enhancers and inhibitors and dairy products really shine for calcium in this respect. I spent a lot of my career intrinsically labeling foods that are rich sources of calcium or some other nutrients and feeding them to follow the tracer to determine absorption. So in the case of dairy products we intrinsically labeled lactating cow with stable isotopes of calcium and we aseptically packaged them after homogenizing and processing the milk. I went to craft and made some dairy products including yogurt and cheese that's be making cheese at the bottom and we did a crossover comparisons in healthy white women aged 24 to 42 and there were no significant differences in bioavailability of calcium from any of these dairy products fed at the same calcium load. So we removed the load confounder and they were all equally bioavailable but life stage makes a difference. If you feed the milk to different life stages you have different absorption capacity so if you look at the bottom left kind of center the teenagers that I study a lot their calcium absorption efficiency from one glass of milk or one cup of yogurt is about 40 percent efficient whereas the counselors a little bit older college students like in the back the top the top of that picture their absorption has fallen to fallen to about 30 percent and if you're as low as old as me in the front it's down around 25 percent and we've studied 75-year-old women it's down like five percent so life stage your capacity for absorption efficiency really differs across the life stage now contrast all of that with lactating women that we intrinsically labeled and followed calcium absorption into the breast feeding infants and had an average calcium absorption of 80 percent so much different. Now we've also compared milk head-to-head against supplements at the same calcium level that's rarely been studied direct comparisons for alkyne major and we were looking at bone properties so objectives of this study were to directly compare non-fat dry milk and calcium carbonate for bone acquisition in growing female rats so they all had adequate levels of calcium and they all got the complete vitamin and mineral mix so that they were not supposed to be deficient in anything they were all adequate it's just the source of calcium that was different and we can control the diet and feed it long enough in animals that we can see hard outcome measures then we also wanted to determine was there any lingering protective effect of early feeding of calcium as non-fat dry milk or calcium carbonate on bone maintenance in mature rats so how we designed the study to address these two questions we started with wainling rats and put them on adequate calcium as calcium carbonate or non-fat dry milk we sacrificed 50 rats per group at the end of 10 weeks when they're nearly adult mature bones and the rest we either kept on the same calcium carbonate or non-fat dry milk diet or we were imitated what a postmenopausal woman might achieve half enough calcium and then the calcium was as calcium carbonate instead of dairy so the benefit to the growing rats of getting calcium as milk product instead of calcium carbonate were that the bones were bigger longer wider more dense took more energy to failure had a greater micro architecture like as illustrated in cortical thickness compared to the rats fed calcium carbonate and in the mature rats who went on the half enough calcium as all calcium carbonate there were these lingering benefits if they had been grown on the non-fat dry milk as a source of calcium earlier in life then if they had been grown on calcium carbonate the bones were still more dense more calcium per bone higher breaking strength and cortical thickness so we found milk during growth conferred substantial benefits to bone over nutritionally adequate diets that help protect against calcium deficits later in life if you look at early life exposure in utero this is a study in india where they looked at what the pregnant mother was consuming in terms of dairy products and then related to the child bone mineral density at age six so this is divided up as milk or milk products largely yogurt and cheese or all calcium rich foods and it was the same story if they had more dairy products than every other day there was a significant advantage over the low rarely or never consuming dairy products so starts really early if you look at during growth randomized controlled trials of milk you've heard i think the henturek meta analysis of calcium supplementations in dairy showing that if you start out on a lower calcium intake and you have a supplemented period then you have a bigger gain in bone this is one of the best done trials in that respect it's an 18 month randomized controlled trial on one pint of milk in 82 white girls margo barker's lab did this she's in the audience and you see this significant increase in total body bone mineral content so these girls started at baseline at 740 milligrams per day it has to be a low calcium intake to start with to show the benefit because calcium is a threshold nutrient and i'll illustrate that with a study that we just completed and was um defended in my doctoral students thesis just last week that's how new these data are but we did a also an 18 month randomized controlled trial in healthy weight and overweight boys and girls to determine the effective dairy intervention on bone mass accrual and strength and a major defective dairy intervention on body composition so fourth fourth through eighth grade boys and girls were recruited 240 of them randomized to either the healthy we recruited half that were healthy bmi which were the fifth to the 70th percentile for age or elevated bmi greater than 85 for age equal numbers and either they were on their self-selected diet with no additional dairy or we provided them three servings of dairy per day one had to be milk one had to be yogurt and the other one could be cheese milk or yogurt and we didn't see any benefit over two servings of dairy a day in change in total body bone mineral content or any other major including pqct the kinds of evidence that we had to set three cups of milk a day on relationship to health outcome measures for bone in the 2005 dietary guidelines or studies like this in children milk avoiders have higher fracture risk than those who consume milk this is out of new zealand this was kind of first of its type looking at milk avoiders versus milk consumers so the fracture risk was 34.8 percent in milk avoiders compared to their birth match control of 13 percent and here's kind of the same story in adults so let me divert just a minute and take on andrew prentice a little bit for this morning because he showed you an inter-country comparison saying the more milk a country drank the higher the incidence of hip fracture you really it's he's worried about confounders that's the most confounded case i could imagine is comparing across countries you just one little example in asia they have a shorter femoral neck so if they fall with the same bone mineral content they're going to have a lower chance of fracturing the hip they have a higher incidence of vertebral fracture so you have to go by site you have to go by genetics you have to go by geometry physical activity all sorts of things in fact renae risoli and our bone work workshop next door showed this wonderful even stronger comparison between numbers of books in the library in a country compared to incidence of hip fracture so maybe a number of books in the library mean a higher income you live longer you're going to have more hip fractures documented in that longer lifespan you don't know what it is from observational relationship study or inter-country comparison so a study like this is a lot more meaningful all in finland you're taking milk avoiders because they're lactose intolerance versus those who consume milk and so the dairy calcium intake is quite different between the lactose intolerant and the lactose tolerant and the odds ratio for fracture is 1.33 in the lactose intolerant compared to the lactose intolerant and if you do lower lower body excluding ankle the odds ratio rises to 2.15 we looked at retrospective studies in the 2005 dietary guidelines like this one by Heidi Kalkorf that showed lower milk intake during childhood double the risk of hip fracture in Caucasian women from N. Haynes we didn't just look at bone we looked at other factors that you've seen today more updated but at that time for the cardio at study all the measures of insulin resistance syndrome were suppressed with increasing dairy consumption and this was a big study in determining three servings a day because the best results were for three servings a day and additional servings didn't further reduce metabolic syndrome factors we also paid a lot of attention to the dash diet for lowering blood pressure so here's the three arms of dash the control which is a western diet the one with lots of fruits and vegetables and this additional benefit by having three servings of dairy kind of equivalent in lowering blood pressure very influential for our committee there was a perspective study on dairy and stroke that if you had more than two cups of milk a day the hazard ratio was 0.64 and 0.37 if they had had a prior vascular event these all really influenced that three servings of milk a day so in conclusion the benefits of dairy and the dietary guidelines are that milk and milk products are the best and most economical source of many limiting nutrients a diet low in dairy tends to be poor in calcium potassium vitamin D and many other nutrients milk has a source of calcium during growth results in bigger denser stronger bones than calcium supplements and protects against calcium deficiency later in life and milk and milk products have protective effects for bone health insulin resistance syndrome and stroke thank you