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Journal of the American College of Nutrition
ISSN: 0731-5724 (Print) 1541-1087 (Online) Journal homepage: http://www.tandfonline.com/loi/uacn20
Cow’s Milk Consumption and Health: A Health
Professional’s Guide
Franca Marangoni, Luisa Pellegrino, Elvira Verduci, Andrea Ghiselli, Roberto
Bernabei, Riccardo Calvani, Irene Cetin, Michelangelo Giampietro, Francesco
Perticone, Luca Piretta, Rosalba Giacco, Carlo La Vecchia, Maria Luisa
Brandi, Donatella Ballardini, Giuseppe Banderali, Stefano Bellentani,
Giuseppe Canzone, Claudio Cricelli, Pompilio Faggiano, Nicola Ferrara,
Evelina Flachi, Stefano Gonnelli, Claudio Macca, Paolo Magni, Giuseppe
Marelli, Walter Marrocco, Vito Leonardo Miniello, Carlo Origo, Filomena
Pietrantonio, Paolo Silvestri, Roberto Stella, Pasquale Strazzullo, Ersilia
Troiano & Andrea Poli
To cite this article: Franca Marangoni, Luisa Pellegrino, Elvira Verduci, Andrea Ghiselli, Roberto
Bernabei, Riccardo Calvani, Irene Cetin, Michelangelo Giampietro, Francesco Perticone, Luca
Piretta, Rosalba Giacco, Carlo La Vecchia, Maria Luisa Brandi, Donatella Ballardini, Giuseppe
Banderali, Stefano Bellentani, Giuseppe Canzone, Claudio Cricelli, Pompilio Faggiano, Nicola
Ferrara, Evelina Flachi, Stefano Gonnelli, Claudio Macca, Paolo Magni, Giuseppe Marelli, Walter
Marrocco, Vito Leonardo Miniello, Carlo Origo, Filomena Pietrantonio, Paolo Silvestri, Roberto
Stella, Pasquale Strazzullo, Ersilia Troiano & Andrea Poli (2018): Cow’s Milk Consumption
and Health: A Health Professional’s Guide, Journal of the American College of Nutrition, DOI:
10.1080/07315724.2018.1491016
To link to this article: https://doi.org/10.1080/07315724.2018.1491016
Published online: 24 Sep 2018.
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Cow’s Milk Consumption and Health: A Health Professional’s Guide
Franca Marangoni
a
, Luisa Pellegrino
b
, Elvira Verduci
c
, Andrea Ghiselli
d
, Roberto Bernabei
e
, Riccardo Calvani
e
,
Irene Cetin
f
, Michelangelo Giampietro
g
, Francesco Perticone
h
, Luca Piretta
i
, Rosalba Giacco
j
,
Carlo La Vecchia
k
, Maria Luisa Brandi
l
, Donatella Ballardini
m
, Giuseppe Banderali
n
, Stefano Bellentani
o
,
Giuseppe Canzone
p
, Claudio Cricelli
q
, Pompilio Faggiano
r
, Nicola Ferrara
s
, Evelina Flachi
t
, Stefano Gonnelli
u
,
Claudio Macca
v
, Paolo Magni
w
, Giuseppe Marelli
x
, Walter Marrocco
y
, Vito Leonardo Miniello
z
, Carlo Origo
aa
,
Filomena Pietrantonio
bb
, Paolo Silvestri
cc
, Roberto Stella
dd
, Pasquale Strazzullo
ee
, Ersilia Troiano
ff
, and
Andrea Poli
a
a
NFI–Nutrition Foundation of Italy, Milano, Italy;
b
Department of Food, Environmental and Nutritional Sciences, Universit
a degli Studi di
Milano, Milano, Italy;
c
Department of Health Sciences, San Paolo Hospital, ASST Santi Paolo e Carlo, Universit
a degli Studi di Milano and
SIP–Italian Society of Pediatrics, Milano, Italy;
d
CREA–Alimenti e Nutrizione, Consiglio per la ricerca in agricoltura e l’analisi dell’economia
agraria, Roma and SISA–Italian Society of Nutritional Science, Roma, Italy;
e
Institute of Internal Medicine and Geriatrics- Catholic University
of the Sacred Heart, Roma, Italy;
f
Department of Biomedical and Clinical Sciences, Unit of Obstetrics and Gynecology, Hospital Vittore Buzzi,
Milano, Italy;
g
School of Sports, CONI–Italian National Olympic Committee, Roma, Italy;
h
Unit of Obstetrics and Gynecology, Hospital Vittore
Buzzi, Universit
a degli Studi “Magna Graecia”, Catanzaro and SIMI–Italian Society of Internal Medicine, Catanzaro, Italy;
i
Alimentary Science
and Human Nutrition, Universit
a Campus Biomedico, Roma, Italy;
j
Institute of Food Science, National Research Council, Avellino and SID –
Italian Diabetes Society, Avellino, Italy;
k
Department of Clinical Sciences and Community Health, Universit
a degli Studi di Milano, Milano,
Italy;
l
Fondazione F.I.R.M.O, Firenze, Italy;
m
ANSISA–Italian Association of Food Science Specialists, Milano, Italy;
n
Department of Health
Sciences, San Paolo Hospital, ASST Santi Paolo e Carlo, Universit
a degli Studi di Milano and SINUPE–Italian Society of Pediatric Nutrition,
Milano, Italy;
o
SIGE–Italian Society of Gastroenterology and Digestive Endoscopy, Modena, Italy;
p
Obstetrics and Gynecology Unit, San
Cimino Hospital, Termini Imerese and SIGO–Italian Society of Gynecology and Obstetrics, Termini Imerese, Italy;
q
SIMG–Italian Society of
General Medicine, Firenze, Italy;
r
Cardiology Division, Spedali Civili and University of Brescia and GICR–Italian Association for Cardiovascular
Prevention and Rehabilitation, Brescia, Italy;
s
Department of Translational Medical Sciences, University of Naples ‘Federico II’and
SIGG–Italian Society of Gerontology and Geriatrics, Naples, Italy;
t
SIPREC–Italian Society for Cardiovascular Prevention, Milan, Italy;
u
Department of Medicine, Surgery and Neuroscience, University of Siena and SIOMMS–Italian Society for Osteoporosis, Mineral Metabolism
and Bone Diseases, Siena, Italy;
v
Dietetics and Clinical Nutrition Unit, Spedali Civili Brescia and ADI –Italian Association of Dietetics, Brescia,
Italy;
w
Department of Pharmacological and Biomolecular Sciences, Universit
a degli Studi di Milano and SISA–Italian Society for the Study of
Atherosclerosis, Milano, Italy;
x
Department of Diabetology Endocrinology and Clinical Nutrition, ASST di Vimercate and AMD –Italian
Association of Diabetologists, Vimercate, Italy;
y
FIMMG–Italian Federation of General Medicine Doctors and SIMPeSV–Italian Society of
Preventive and Lifestyle Medicine, Rome, Italy;
z
Department of Paediatrics, University of Bari and SIPPS–Italian Society of Preventive and
Social Pediatrics, Bari, Italy;
aa
Department of Pediatric Orthoaedics, A.O. SS Antonio e Biagio e Cesare Arrigo, Alessandria and SITOP–Italian
Society of Orthopaedics and Traumatology, Alessandria, Italy;
bb
Internal Medicine Unit, - H2-Albano Hospital Center, ASL Roma 6, Roma and
FADOI–Federation of the Associations of Internist Hospital Managers, Manerbio, Italy;
cc
Interventional Cardiology–CCU Department, G.
Rummo Hospital, Benevento and ANMCO–Italian National Association of Hospital Cardiologists, Benevento, Italy;
dd
SNaMID–National
Interdisciplinary Medical Society Primary Care, Milan, Italy;
ee
Department of Clinical Medicine and Surgery, ESH Excellence Center of
Hypertension, "Federico II" University of Naples and SINU–Italian Society of Human Nutrition, Napoli, Italy;
ff
ANDID–Italian Association of
Dietitians, Rome, Italy
ABSTRACT
The most recent scientific evidence supports the consumption of cow’s milk and dairy products as
part of a balanced diet. However, these days, the public and practicing physicans are exposed to
a stream of inconsistent (and often misleading) information regarding the relationship between
cow’s milk intake and health in the lay press and in the media. The purpose of this article, in this
context, is to facilitate doctor–patient communication on this topic, providing physicians with a
series of structured answers to frequently asked patient questions. The answers range from milk
and milk-derived products’nutritional function across the life span, to their relationship with dis-
eases such as osteoporosis and cancer, to lactose intolerance and milk allergy, and have been pre-
pared by a panel of experts from the Italian medical and nutritional scientific community.
When consumed according to appropriate national guidelines, milk and its derivatives contribute
essential micro- and macronutrients to the diet, especially in infancy and childhood where bone
mass growth is in a critical phase. Furthermore, preliminary evidence suggests potentially protect-
ive effects of milk against overweight, obesity, diabetes, and cardiovascular disease, while no clear
data suggest a significant association between milk intake and cancer. Overall, current scientific lit-
erature suggests that an appropriate consumption of milk and its derivatives, according to avail-
able nutritional guidelines, may be beneficial across all age groups, with the exception of specific
medical conditions such as lactose intolerance or milk protein allergy.
ARTICLE HISTORY
Received 17 April 2018
Accepted 17 June 2018
KEYWORDS
Cow’s milk; calcium; lactose;
cardiovascular disease;
metabolic syndrome; cancer
CONTACT Franca Marangoni, PhD marangoni@nutrition-foundation.it NFI–Nutrition Foundation of Italy, Viale Tunisia 38, 20124 Milano, Italy.
ß2018 American College of Nutrition
JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION
https://doi.org/10.1080/07315724.2018.1491016
Key teaching points:
Milk and its derivatives contribute essential micro and macronutrients to the diet, when consumed
according to appropriate national guidelines, especially in infancy and childhood where bone mass
growth is in a critical phase.
Preliminary evidence suggests potentially protective effects of milk against overweight, obesity, dia-
betes and cardiovascular disease
No clear data are available about the association between milk intake and cancer.
Current scientific literature suggests that an appropriate consumption of milk and its derivatives
may be beneficial at all ages, with the exception of specific medical conditions such as lactose
intolerance or milk protein allergy.
Introduction
Bovine milk and dairy products have been part of the
human diet, from birth to old age, for millennia. However,
beyond its nutritional role, milk is the subject of active
research aimed at elucidating the relationship between its
consumption and human health.
In order to summarize the current scientific evidence,
NFI–Nutrition Foundation of Italy convened a panel of
experts and representatives of Italian medical and nutritional
scientific societies, who discussed the available scientific evi-
dence concerning cow’s milk nutrient composition, its
technological and safety aspects, its nutritional role across
age groups and in physiological conditions, and the possible
relationship between milk consumption and specific diseases
and disease risk factors. This article outlines the outcome of
the meeting in a question-and-answer format, in order to
facilitate the work of busy clinicians when answering com-
monly asked patient questions on this topic.
Which nutrients does milk provide?
Milk, that is, cow’s milk, is composed of about 87% water; it
also contains, on average, 3%–4% fat, 3.5% protein, about 5%
lactose, and 1.2% minerals, with some variation depending on
the breed considered (1). In milk marketed for direct con-
sumption, the fat content is usually standardized to the levels
required by law for the three types: whole (>3.5%), semi-
skimmed (1.5%–1.8%), and skimmed (<0.5%) (2). Fat,
mainly represented by triacylglycerols (98%), is present in
milk as globules, ranging from 0.1 to 10 lmindiameterand
surrounded by a membrane (MFGM, or milk fat globule
membrane), composed of several layers of phospholipids and
about 40 different proteins (3) endowed with multiple enzym-
atic activities and involved in various metabolic processes.
The presence of MFGM, for example, is associated with a
more favorable lipid and low-density lipoprotein (LDL) chol-
esterol response to milk consumption compared to butter oil,
an MFGM-free dairy product devoid of phopholipids (4).
About 60% of total fatty acids in milk are saturated fatty
acids, mainly represented by palmitic (16:0, about 30% of
total fatty acids), followed by myristic and stearic acids (14:0
and 18:0, 10% and 12%, respectively, on average). About
10% of milk fatty acids are short-chain saturated (with 4, 6,
8, or 10 carbons), infrequently found in other commonly
used foods (2). Among the unsaturated fatty acids, oleic acid
(18:1, with one double bond) is noteworthy (up to
25%–30%); the essential fatty acids linoleic (18:2 of the n-6
series) and alpha-linolenic (18:3 n-3) are also present in cow’s
milk (2). Milk also contains small amounts of odd-chain satu-
rated fatty acids (pentadecanoic, 15:0, and heptadecanoic acid,
17:0), produced in the cow’s rumen, which are rather pecu-
liar, and are hence used as biomarkers of dairy fat intake (5).
Typically found in milk are also specific trans fatty acids,
including conjugated linoleic acid (or CLA, 18:2 with two
conjugated double bonds), produced by incomplete biohydro-
genation of linoleic acid (18:2 n-6) in the rumen (2).
Carbohydrates in milk are almost exclusively represented
by lactose, a disaccharide, which must be cleaved into glu-
cose and galactose by the intestinal enzyme lactase (or beta-
galactosidase) to be absorbed (6).
Eighty percent of the protein fraction of cow’s milk is
caseins, which predominantly contain glutamic acid, proline,
arginine, and branched amino acids (leucine, isoleucine, val-
ine). Beta-casein, representing about 35% of total caseins,
exists in two different forms (A1 and A2), with possibly dif-
ferent physiological effects (7). Soluble whey proteins rich in
cysteine, lysine, leucine, and tryptophan account for the
remaining 20% of milk proteins (8).
Milk proteins are of high biological value, both because
they contain all the essential aminoacids required by the
human body, and because of their high digestibility and bio-
availability (high protein digestibility-corrected amino acid
score [PDCAAS value]).
Finally, milk provides a variety of minerals, in particular
calcium and phosphorus, but also potassium, magnesium,
zinc, and selenium and both B-group water-soluble vitamins
(riboflavin and B
12
) and fat-soluble vitamins (e.g., A and E)
in concentrations directly related to its lipid content (1).
Safety and keeping quality of milk intended for direct con-
sumption can be achieved by heat treatment under different
conditions, which are summarized in Table 1 (1).
How is raw milk processed and how do such
processes affect its nutritional quality?
Pasteurization and ultra-high temperature (UHT) steriliza-
tion destroy the most common pathogens of raw milk
(Listeria,Campylobacter, pathogenic Escherichia coli strains
2 F. MARANGONI ET AL.
[VTEC], Salmonella, coagulase-positive staphylococci).
Pasteurization, which is carried out by heating raw milk to
at least 72 C for 15 seconds, is the mildest heat treatment; it
destroys non-spore-forming pathogens and reduces the gen-
eric total flora, and the resulting product can be stored at
4–6C for a few days. Pasteurization is recommended for
all milk for human consumption by many medical and
scientific organizations, like as the Food and Agriculture
Organization, the Centers for Disease Control and
Prevention, the Food and Drug Administration (FDA), the
American Academy of Pediatrics, and others.
With UHT sterilization, raw milk is heated to a tempera-
ture between 135 C and 150 C for 4–8 seconds and pack-
aged under aseptic conditions, to ensure complete bacterial
destruction and inactivation of heat-sensitive enzymes; steri-
lized milk can be stored at room temperature for at least 3
months. Both types of milk maintain the nutritional charac-
teristics of the original product almost completely, while
ensuring safety and health. Heat treatments only moderately
reduce the concentrations of some vitamins (especially C,
B
6
, and B
1
), but not of others (A, E and D, B
2
)(1).
Bacteria can also be physically removed, for example, via
microfiltration through porous membranes that retain bac-
terial and somatic cells and spores. Subsequently, complete
safety is ensured via pasteurization.
Lactose-free or low-lactose milk (i.e., <0.01% and <0.1% lac-
tose by weight), suitable for consumption by lactose-intolerant
individuals, is obtained by adding beta-galactosidase to milk
before heating, thus leading to the release of glucose and galactose.
Powdered milk, used as an ingredient in a number of
industrial products, is produced by dehydration of fluid
milk. During this process, the Maillard reaction produces
specific derivatives (which are globally evaluated, for
example, determining the “blocked lysine”levels), but the
overall effect is similar to that observed with UHT processes
(9). Once reconstituted, powdered milk presents the same
composition and nutritional value as native milk, provided
it is not stored for too long or exposed to light or humidity.
What about the safety of milk marketed for human
consumption?
Minimizing possible health risks associated with milk con-
sumption requires a continuous system of preventive meas-
ures starting from animal feed suppliers, farmers, and milk
processors to good hygiene practices and food safety man-
agement throughout the production chain, as defined, for
example, in the Pasteurized Milk Ordinance (PMO) pub-
lished in 2009 by the FDA, in the Canadian National Dairy
Code or in the European Regulations 853/2004, 1881/2006,
2073/2005, and 37/2010.
The regulation on milk and milk products addresses ani-
mal health, hygiene of milk production, storage, packaging,
and specific criteria related to production and distribution
of raw milk, that is, unpasteurized milk. As an example,
acceptable upper limits have been fixed for total bacterial
count and somatic cells (possible markers of breast inflam-
mation) to be fulfilled in raw milk, and may be different
from one country to another. The aim behind this approach
is to prevent heating abuse when sanitizing low-quality raw
milk. The presence of aflatoxins (from feed contamination),
contaminants, and pathogens is also kept under control.
Moreover, milk marketed for human consumption should
not present any antibiotic residue.
Finally, the use of hormones for fattening purposes (known
as “feeding hormones”) in livestock production or to stimulate
lactation was banned many years ago in the European Union,
Canada, Australia, New Zealand, and Japan, which share a
common view of the animal and human health concerns.
Milk consumption: recommendations of
nutritional guidelines
Despite the cross-country variability of recommendations
for milk and dairy products, all international guidelines rec-
ommend daily consumption of milk (and yogurt) (1).
The main differences among countries relate to the consid-
eration of milk (and yogurt) alone or their inclusion in the
category of dairy products: in Finland and Denmark, for
example, the recommendations refer to 500 ml of milk per
day; in Italy, the United Kingdom, Spain, and the
Netherlands the reference intakes are based on serving num-
ber (about 2–3 milk servings per day, with 1 daily cheese
serving in the Netherlands and 2–3 weekly servings of cheese
in Italy); the United States, Canada, and Australia share rec-
ommendations of about 2–3 servings per day (according to
age and requirements) of fat-free or low-fat dairy products
(selected from 1 cup of milk or yogurt and 1 and 1
=
2oz
cheese). Moreover, the standard milk serving size differs con-
siderably across countries: from 125ml in Italy to 150ml in
the Netherlands, 200 in the United Kingdom, and about
250 ml in Spain, the United States, Canada, and Australia.
What nutritional role does milk play in the first
years of life?
Whole cow’s milk should not be used as the main dietary
component during the first 12 months of life, in order to
Table 1. Main Types of Commercially Available Milk for Direct Consumption.
Heating conditions Typical durability and storage conditions
Fresh pasteurizedmilk: 72–78 C for 15–20 seconds 6 days at 4–6C
“High quality”freshpasteurized milk: 72 C for 15-–18 seconds (minimum required conditions) 6 days at 4–6C
Microfiltered pasteurized milk: Microfiltration (removal of bacterial cells) and subsequent pasteurization 15–18 days at 4–6C
High-temperature pasteurized milk 90 C for 20–30 seconds or 100–120 C for 0.1–0.4 seconds 15–18 days at 4–6C
UHT (ultra-high-temperature) milk 135 to 150 C for 4–8 seconds 3 months at least, room temperature.
Lactose-free milk Pasteurization or UHT treatment with enzymatic hydrolysis of lactose Dependent upon treatment
Powdered (dried) milk Pasteurization, evaporation drying Room temperature
The terms “pasteurized fresh milk”and “high quality fresh milk”are defined by Italian law (Regulation 169/89 and Ministerial Decree 185/91).
JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION 3
provide optimal nutritient supply to the infant, to avoid an
excessively high protein intake, as well as of energy and fat
during complementary feeding and to reduce the risk of
subsequent overweight or obesity (especially in predisposed
individuals) (10,11).
In observational studies, a high intake of total animal and
dairy protein in toddlers (i.e., 1–3 years of age) has also
been associated with increased body mass index (BMI) at
later ages (12,13). However, the effect of cow’s milk after the
first year of life is less well understood, due to the lack of
data from randomized clinical trials. It has been suggested
that there be a limit on the consumption of cow’s milk to
200–400 ml/d, in order to maintain the overall diet protein
content below 15% of total calories (14,15).
Taking into account the available evidence, all the
national/international guidelines recommend, starting from
the second year of life, milk and/or yogurt consumption on a
daily basis, especially for its digestible protein and calcium
content, essential for growth. Milk has also been placed at the
bottom of the food pyramid defined by the Italian Society of
Pediatrics, among the foods for which a daily consumption is
suggested. Other international guidelines such as those of the
American Academy of Pediatrics, or the European Society for
Paediatric Gastroenterology Hepatology and Nutrition and
the Food and Agriculture Organization, agree upon the role
of cow’s milk as a component of a balanced diet for chil-
dren (16).
Are there relevant reasons to exclude cow’s milk
from the diet of healthy children?
The replacement of cow’s milk with other types of milk
(such as donkey milk, for which the low fat content makes
it unsuitable for pediatric diets) or with plant-based drinks
(which can no longer be labeled as “milk”in Europe,
according to Regulation [EU] 1234/2007) to gain supposed
health effects, in the absence of diagnosis for specific dis-
eases, is becoming a widespread practice. However, such an
approach is not supported by adequate scientific evidence,
and has no proved benefits for the general healthy popula-
tion, including children. Specifically, the content of selected
micronutrients in vegetable alternatives to cow’s milk (which
often contain less protein and calories) is variable and
strictly dependent upon the degree of enrichment (e.g., as
concerns calcium and phosphorus).
In addition, no association has been ascertained between
cow’s milk consumption and autism, despite this issue being
occasionally raised by the media. On the contrary, cow’s
milk is a well-recognized marker of the proper habit of hav-
ing breakfast, which is an important factor affecting the
nutritional quality of the diet at pediatric ages (17,18).
Therefore, children should not use any alternative to cow’s
milk in the absence of a specific indication provided by the
pediatrician. Both doctors and families must also address
incorrect nutritional children’s habits, including the progres-
sive reduction in milk consumption from school age to
adolescence.
Is it true that consuming milk in early life increases
the risk of overweight and obesity in adulthood?
In the early years of life, as previously mentioned, attention
should be paid to protein intake (and hence to the intake of
all protein sources, including cow’s milk) because an intake
exceeding 15% of total energy has been associated with the
risk of overweight and obesity later in life (19). Some obser-
vations suggest that excessive protein intake increases the
synthesis of insulin-like growth factor 1 (IGF-1), which is
involved in overweight and obesity programing (20).
Based on studies carried out in northern Europe, where
circulating levels of IGF-1 increase along with milk con-
sumption, it was hypothesized that milk proteins (casein dir-
ectly and whey protein indirectly) were responsible for
accelerated weight growth and adipogenic activity (14).
However, IGF-1-mediated adiposity is a rather complex pro-
cess, which has been demonstrated only in infants who
received protein intakes with infant formulas markedly
exceeding needs, and it has not been confirmed in older
children (14,15). For example, among 99 children from the
Framingham Children Study, those in the lowest tertile of
milk consumption (less than 1.25 servings for females and
less than 1.7 servings for males) at preschool age exhibited
increased accumulation of subcutaneous fat during adoles-
cence, in comparison with children in the highest tertile
(21). Moreover, higher consumption of milk and yogurt by
adolescents was associated with lower accumulation of body
fat and lower cardiometabolic risk in the European multi-
center study HELENA (22).
How does cow’s milk contribute to calcium intake?
Milk products are important sources of protein, vitamins
(e.g., retinol, vitamins B
2
and B
12
), phosphorus, and zinc, as
well as of calcium, for both adolescents and adults (23). In
fact, based on the EPIC data, milk and its derived food prod-
ucts account for about 50% of the daily calcium intake in this
European cohort (24). Diets including small amounts of milk
and yogurt, followed by specific populations (e.g., Italian
females), are—on average—inadequate in terms of calcium
supply (25,26). Obviously, other foods, namely, plant-based
ones (legumes, almonds, parsley, and sage), also contain con-
siderable concentrations of calcium. However, if the calcium
content, the energy value per serving, and the relative cost of
each food item are taken into consideration, it is possible to
conclude that cow’s milk remains the more advantageous cal-
cium dietary source, supplying energy, high-quality protein,
calcium, and also essential fatty acids, at a fairly low price.
The benefit of products belonging to the milk group has been
confirmed also after the assessment of costs in terms of
energy, euros, and nutrients to limit (saturated fatty acids,
added sugar and sodium) associated with calcium supply
equivalent to 15% of the European Union (EU) daily refer-
ence value (120 mg) (27). Furthermore, calcium in milk and
dairy products is highly bioavailable (28).
4 F. MARANGONI ET AL.
What nutritional role can cow’s milk play for
pregnant or breastfeeding women?
During pregnancy the nutritional phenotype changes
remarkably, and modifications involve not only the woman’s
body, but also the placenta and the fetus, which grow as
effective organs with active metabolisms, in turn affecting
maternal metabolism (in the second trimester of pregnancy,
about 50% of nutrients are used by the placenta) (29).
However, the energy requirement during pregnancy is only
modestly increased (þ100–300 kcal/d from the first to the
third trimester), compared to the significant increase in
micronutrient (vitamins and minerals) requirements (30). As
a result, during pregnancy, the diet should be qualitatively
improved rather than calorically increased. Many studies
show that nonoptimal dietary patterns (different from the
Mediterranean or the “prudent”ones) increase the risk of
both short- and long-term adverse effects such as infertility,
spontaneous abortion, diseases in late pregnancy, or risk fac-
tors for the newborn’s health (31).
Nowadays, increasing importance is given to epigenetic
modifications, modulated by the maternal nutritional status
at conception, but also reflecting the energy and micronu-
trient intake in the periconceptional period (32).
During pregnancy, both deficiency and excess (e.g., protein
intake falling outside 10%–15% of total calories), may
adversely affect the infant’s weight at birth. In this context,
food sources of proteins with high biological value, such as
milk and derivatives, play an important role (33). Research
carried out in northern Europe showed significant correla-
tions between intakes of dairy products in pregnancy and
birth weight (34), height of the offspring measured at 20 years
(35), reduction of the risk of developing milk allergy (36),
and protection from the risk of postpartum depression (37).
In 2012, the European Food Safety Authority (EFSA) Panel
on Dietetic Products, Nutrition and Allergies proposed an
additional intake of 1, 9, and 28g/d of proteins, respectively,
in the first, second, and third trimesters of pregnancy, over
the reference intake (PRI) defined for nonpregnant women
(30). A protein intake of 19 g/d and 13 g/d is also proposed
in addition to the PRI during the first 6 months and after 6
months of breastfeeding, respectively.
The most solid data concern the contribution of milk-
derived products to calcium intake. Calcium is essential for
the formation of bones and for the health of the skeleton of
mothers and children, but calcium supplementation
throughout pregnancy also reduces the risk of developing
hypertension and pre-eclampsia, especially in women with
low mineral intakes (38). Supplementation with 1.5–2g of
calcium per day is in fact recommended by the World
Health Organization (WHO) for pregnant women with
inadequate dietary intakes.
Particular attention should also be paid to the maternal
status of vitamin D—largely dependent on the consumption
of animal foods, including milk—which has multiple roles in
pregnancy: not only to support bone growth and fetal and
maternal health, but also to promote immunological devel-
opment and the prevention of both pre-eclampsia and infant
allergies. Dietary intake of vitamin D often falls below the
recommendations in all high-income countries (39).
Finally, ongoing studies reveal associations between posi-
tive outcomes of pregnancy and overall quality of the mater-
nal diet, especially if it includes—in addition to fish, whole
grains, and red fruits—milk and its derivatives.
What is the nutritional role of milk in the elderly? Is
there any specific reason to limit the consumption
of cow’s milk in old age?
An adequate intake of high-quality protein, such as that
contained in cow’s milk, along with appropriate physical
activity, is essential to counteract the progressive loss of
muscle mass and strength which typically begins during the
fourth decade of life (40). This decline accelerates past the
age of 65 years, potentially leading to sarcopenia (41).
According to the ESPEN Group, individuals over 65 years
of age should consume at least 1.0–1.2 g per kg body weight
per day, and as much as 1.2–1.5 g/kg/d in the presence of
acute or chronic diseases (42). Recent evidence suggests that
consumption of milk protein in combination with resistance
training is more effective at improving muscle strength com-
pared to vegetable protein (43).
Other nutrients contained in milk, such as calcium, phos-
phorus, and vitamin D, are of great importance in the elderly
as they play both structural and functional roles in bone and
muscle, thereby reducing the risk of falls and fractures (44,45).
Recent studies also suggest that another milk trace com-
ponent, nicotinamide riboside, a niacin-derived substance
(vitamin B
3
), may act on NAD metabolism and sirtuins,
which in turn possess anti-aging properties (46).
Are there specific indications or contraindications
regarding the consumption of milk by [professional
or amateur] athletes?
Milk may play an important role in supporting competitive
and amateur sports activities as a source of protein and
minerals during recovery after exercise. The simple carbohy-
drate (lactose) content in milk (50 g/l) is similar to that of
many drinks specifically formulated for sports, containing
glucose or maltodextrin, which are quickly absorbed from
the gut. Milk also presents a high concentration of electro-
lytes, which can replace those lost with sweat during exer-
cise: The rehydrating capacity of skim milk after training is
comparable to that of hydrosaline sports drinks (47).
Furthermore, a recent study in physically active men dem-
onstrated that skim milk performed better than other drinks
(milk, water, sports drinks) in restoring and maintaining
water balance after exercise and loss of fluids due to heat
exposure (48).
In addition, the consumption of 250–500 ml of milk in
the first hour after training may promote muscle recovery
and contribute to increasing muscle mass. Subjects who
ingested 500 ml of skim milk immediately after resistance
training maintained anabolic activity, resulting in increased
protein synthesis in muscles (49). Similar results were also
JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION 5
obtained by other authors, who propose low-fat milk as a
safe and effective “sports drink”(50).
What is the relationship between milk consumption
and bone mass, osteoporosis, and risk of fracture?
Protein, calcium, phosphorus, magnesium, manganese, zinc,
and vitamin K, provided in good amounts by cow’s milk
and dairy products, are necessary to build a solid skeletal
system in infancy and adolescence and to maintain bone
structure during adulthood (51).
According to the results of a meta-analysis, consumption of
milk and derived products (with or without vitamin D supple-
mentation) increases calcium concentrations in both the
bloodstream and the lumbar spine in children with low basal
milk intake (but not in children with high milk consumption)
(52). Moreover, the inadequate supply of calcium and phos-
phorus associated with low milk consumption during child-
hood and adolescence has been linked with an increased
incidence of osteoporotic fractures among older women (53).
Furthermore, magnesium, which is also provided by
cow’s milk, may be more important than calcium for bone
development in children and adolescents (except for those
with a very low calcium intake) (54).
In adults, consumption of diets providing adequate amounts
of protein, calcium, phosphorus, and vitamin D reduces bone
resorption, slowing down age-related bone loss (44).
Most likely due to the complex interactions regulating
bone metabolism and the availability of nutrients with dif-
ferent food sources, the published evidence of a clear rela-
tionship between milk consumption in adulthood and the
risk of osteoporosis and risk fractures in later years is not
entirely consistent (55). However, according to a systematic
review of the literature, both milk and calcium are positive
determinants of bone health in adults (56). Furthermore, the
available data are mostly in favor of a positive role of milk
and calcium in bone mass maintenance and of selected dairy
sources of calcium in the reduction of the risk of hip frac-
tures (57,58). On the contrary, there is no evidence of
plasma acidification following milk consumption (a concept
rather widespread on the Web and among the “no milk”
movement), or of the release of calcium by the bone matrix
aimed at buffering such purported plasma acidification (59).
Further studies should establish the actual effectiveness of
vitamin D-enriched dairy products in increasing the protect-
ive effect of vitamin D on the risk of fractures.
An additional benefit at the skeletal level could be pro-
vided by milk proteins (in particular whey proteins), by
stimulating the release of IGF-1 and by promoting GH
metabolism in bones, also in old age (60).
Milk allergy and lactose intolerance: how can we
frame the problem and what are the most
appropriate strategies for mitigating its effects?
Lactose intolerance and milk allergy are often confused by
the lay public, despite their different pathophysiology and
clinical consequences.
Milk allergy is especially common in infancy and repre-
sents one of the most common allergies, together with egg
allergy; its prevalence is about 2%–3% of children in the first
year of life and then decreases with age (61). One or more
cow’s milk proteins (casein or serum albumin) usually trig-
ger milk allergy. The reaction is often shared by milk of
other animal species, with the risk of cross-reactivity (62).
The allergic reactions are mediated by immunoglobulin
(Ig) E in about half/two-thirds of cases and by non-IgE-
mediated mechanisms in the remaining cases. In IgE-medi-
ated allergies, symptomatology can range from skin reac-
tions of varying intensity to potentially fatal, but rare,
anaphylactic shock (63). Non-IgE-mediated reactions, to the
contrary, usually cause gastrointestinal disorders, often diffi-
cult to interpret (64).
Lactose intolerance, on the other hand, is caused by the
absence, or the reduction, of lactase (beta-galactosidase)
activity, necessary to hydrolyze lactose and subsequently
promote monosaccharide absorption (6). Lactase deficiency
(also defined as lactase nonpersistence) affects about 70% of
the world’s adult population and often emerges in adoles-
cence or during adulthood. The reduced digestion of lactose
due to lactase absence/deficiency is therefore very frequent,
except in northern Europe or North America, where lactase
persistence is most common (65). If not digested, lactose
remains in the lower intestine, where it calls for water by
osmosis and is metabolized by the local microbial flora, with
formation of water and gas (CO
2
and hydrogen) in quanti-
ties related to the amount of lactose consumed and to the
extent of lactase deficiency. This results in cramping,
abdominal pain, bloating, and diarrhea (66). When it is
deemed necessary by the clinician, lactose malabsorption
can be diagnosed by administering 20 or 50 g of lactose in
the fasted state: High levels of breath hydrogen, caused by
the bacterial fermentation of undigested lactose, confirm the
lactase deficiency. However, an increase in breath hydrogen
merely indicates lactose malabsorption, whereas for diagnos-
tic purposes, specific symptoms associated with bacterial fer-
mentation of undigested lactose must be observed (67).
Many patients, on the other hand, report symptoms even in
the absence of markers of malabsorption (the peak of
exhaled hydrogen).
Individuals with a diagnosis of lactose malabsorption will
not necessarily develop symptoms when consuming lactose
containing food. In fact, symptom appearance may be
affected by the absolute amount of lactose ingested, the
residual activity of intestinal lactase, and the gastric empty-
ing speed, the intake of lactose containing foods, the lactose
fermentation rate by intestinal microbiota, and the individ-
ual sensitivity to lactose fermentation products.
Available data, reviewed by, indicates that adults and
adolescents with lactose malabsorption can generally ingest
up to 12 g of lactose administered in a single dose (equiva-
lent to the lactose content of a cup of milk) without
unpleasant effects or with mild ones; however, sensitivity
may greatly vary across individuals. Tolerance is generally
greater if lactose is consumed with meals and in smaller
doses (68). Frequent lactose ingestion may increase the
6 F. MARANGONI ET AL.
amount of lactose tolerable by adults and adolescents, but
the data remain highly controversial.
The use of lactose-free milk and/or lactose-free dairy
products, or even of lactase before meals, allows lactose-
intolerant individuals to consume milk and milk derivatives
without gastrointestinal symptoms. In general, ripened
cheeses contain minimal amounts of lactose, and lactase
produced by yogurt lactobacilli can contribute to the
digestion of lactose consumed in yogurt (a so-called “post-
biotic”effect).
Is there any relationship between cow’s milk
consumption and risk of overweight, obesity, and
type 2 diabetes in adults?
Bioavailable calcium, branched chain amino acids, conju-
gated linoleic acid, proteins, and to some extent vitamin D,
present in milk, have been correlated to a reduced risk of
obesity (69,70). Several studies suggest that calcium can
regulate body weight and fat mass, by reducing de novo
lipogenesis, increasing lipolysis, or interfering with the
absorption of dietary fat via the formation of insoluble soaps
in the intestine (71). Milk proteins, on the other hand, may
regulate weight by stimulating thermogenesis, increasing
satiety, and preserving or increasing lean body mass (72).
However, evidence provided by epidemiological and
intervention studies does not support this purported protect-
ive role of milk consumption in obesity: Controversial
results have been obtained in the available studies, likely due
to the variability of experimental designs, the different
parameters evaluated, and the volume of milk servings con-
sidered (73). Additionally, in studies where a protective
effect on weight is observed, this is modest and not clinically
significant.
The absence of a correlation between milk intake and
body mass index (BMI) has been confirmed by two recent
prospective studies (74,75).
The results of meta-analyses are ambiguous. According to
the analysis of 16 observational studies, both prospective and
cross-sectional—on children and adults—milk consumption
may reduce the risk of obesity by 13% in children and 23%
in adults (76). However, when cross-sectional and prospective
studies were analyzed separately, the protective effect of milk
consumption on obesity risk remained significant for cross-
sectional studies only. On the other hand, a reduction of both
fat mass and risk of becoming obese has been raised by
another meta-analysis of 10 studies on children and adoles-
cents (77). It can be concluded that milk consumption within
adequate diets does not negatively affect body weight, and
associations with a reduction in body weight were only found
in cross-sectional studies, but not in prospective ones.
With regard to the risk of developing type 2 diabetes, a
reduction of about 10% was found in subjects who con-
sumed the highest amounts of milk (either total or low fat)
compared to those with the lowest consumption levels (78).
These results are confirmed by another meta-analysis report-
ing that the relative risk of type 2 diabetes was reduced by
11% in subjects who consumed 200 g/d of low-fat milk (79).
The effect was attributed to low-fat milk, however, not to
the same amount of whole milk and total milk consumption
(80). In a report and meta-analysis including a large cohort
of healthy men and women participating in the Health
Professionals Follow-up Study and Nurses’Health Study I
and II, whole milk consumption did not modify the risk of
type 2 diabetes, which was reduced by 17% by a 1-serving
increase of yogurt (81). Finally, a meta-analysis of prospect-
ive studies, which analyzed about 580,000 subjects, reported
a slight reduction in the incidence of type 2 diabetes associ-
ated with the consumption of total dairy products and, espe-
cially, of yogurt and low-fat milk (in two studies, however,
that were not adjusted for confounding variables) and no
significant association with other types of milk (82).
According to these findings, the protective effects of milk
appear to be more relevant to the development of type 2
diabetes. Current evidence excludes an unfavorable effect of
milk consumption on the risk of developing and type
2 diabetes.
Is there any correlation between cow’s milk
consumption and the risk of developing
cardiovascular or cerebrovascular diseases?
Both within the general population and medical community
there is a widespread belief that consumption of milk (namely,
whole milk) is associated with an increase in cardiovascular or
coronary risk. This is probably due to the high proportion of
saturated fatty acids in milk (about 70% of the total lipid
fraction), which are known to increase LDL cholesterol levels,
a recognized risk factor for coronary heart disease (2).
Yet the most recent meta-analyses and reviews seem to
exclude an effect of milk consumption on cardiovascular
risk. Coronary risk is generally unchanged or not signifi-
cantly increased by milk intake, while the risk of cerebrovas-
cular events (e.g., stroke) is generally reduced. For example,
two meta-analyses by Soedamah-Muthu and colleagues
observed a reduction of cerebrovascular events, and no effect
on coronary risk, in association with milk intake (83).
A reduction in stroke risk (9%) and a neutral effect on
coronary events also emerge from another meta-analysis,
which evaluated the effect of milk and dairy products (mainly
cheese and yogurt) (84). However, a more recent meta-
analysis by Larsson and colleagues did not report a clear
association between milk consumption and the risk of cardio-
vascular events, possibly because of the high heterogeneity
observed among the studies considered (85). However, even
the presence of a gene encoding for lactase persistence induc-
ing higher milk consumption (about 400/500 ml per week)
was not associated with any change in coronary risk in a
recently published Mendelian randomization study (86).
The absence of effects on coronary risk of milk intake,
despite its saturated fat content, fits with the lack of effects
by saturates on coronary risk, as evidenced by the most
recent meta-analysis on the subject, confirming that milk
fatty acids (including some conjugated linoleic acid isomers,
CLA), originating in the rumen, do not seem to affect cor-
onary risk or all-cause mortality (87). Short-chain saturated
JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION 7
fatty acids (from 4 to 10 carbons), which are also typical of
milk, would also have a moderately protective effect on cor-
onary risk, according to a European study (88).
Plasma levels of odd carbon atoms fatty acids (bio-
markers of milk consumption) are associated with a reduc-
tion in the risk of stroke and myocardial infarction in
American and Swedish cohorts (88,89).
In addition, it has been suggested that some milk compo-
nents (calcium and tripeptides that can be cleaved from
casein and/or whey proteins) lower systolic and diastolic
blood pressure (90). A significant effect of milk intake on
blood pressure, on the other hand, has not been confirmed
by a recent Mendelian randomization (91).
Is there a correlation between the consumption of
cow’s milk and cancer?
A supposed association between cow’s milk (and its deriva-
tives) consumption and the incidence of specific cancers is
often emphasized by public opinion. Different mechanisms
of action have been hypothesized to explain these possible
associations (both protective and unfavorable); however,
there is no clear epidemiological evidence in this regard.
According to one theory, calcium would interfere with
vitamin D metabolism and, in association with IGF-1, would
increase the risk of cancer in specific anatomical sites, such
as the prostate (92). According to another hypothesis, cal-
cium could reduce cell proliferation and stimulate differenti-
ation and apoptosis of cells in the gastrointestinal mucosa
and breast; moreover, it could eventually bind to bile acids
and fatty acids produced by bacterial fermentation in the
colon, limiting its contact with the colon wall (93). The sug-
gested specific toxicity of galactose to ovarian epithelial cells
and role of this sugar in promoting neoplastic proliferation
in these cells has been suggested, but has not been con-
firmed by a large population-based case-control study
assessing possible relationships between milk component
intakes and cancer risk (94).
As a matter of fact, the results of epidemiological studies
are quite clear. One of the most relevant publications on the
topic—based on the results of an Italian multicenter study
that included 8,000 cases matched to controls—did not
observe significant associations between milk consumption
and total tumor incidence (95). Similarly, a recent meta-ana-
lysis of four prospective studies did not report this associ-
ation (85,96).
Other studies have examined the correlation between
milk consumption and the incidence of tumors in anatomic
sites or specific organs. Specifically, a meta-analysis of 32
prospective studies reported a modest excess of prostate can-
cer risk associated with an increased consumption of 200 g/d
of total and skimmed milk (risk ratio [RR] ¼1.03, 95% con-
fidence interval [CI] 1.00–1.07) (97). Another meta-analysis
of 19 cohort studies by the same authors reported a modest
reduction in colorectal cancer risk, again associated with a
milk consumption of 200 g/d (RR ¼0.91, 95% CI 0.85–0.94)
(98). A protective association between consumption of total
dairy products, milk, cheese, and dietary calcium intakes
and the incidence of colorectal cancer has been established in
2017 by the World Cancer Research Fund International,
within the Continuous Update Project, an ongoing program
to analyze global research on how diet affects cancer risk and
survival. A modest direct association with prostate cancer and
an equally modest inverse association with colorectal cancer
were also identified in the aforementioned Italian study.
Regarding breast cancer, the consumption of dairy prod-
ucts does not appear to be associated (either positively or
negatively) with significant variations in the risk of this type
of tumor, as evidenced by two meta-analyses, one of more
than 20 studies involving over 350,000 women with an aver-
age follow-up of 15 years (99) and another taking into
account 18 cohort studies, involving 1,063,471 participants
and 24,187 cancer cases (100). Only in the most recent
meta-analysis was a reduction in the risk of cancer associ-
ated with low-fat dairy product consumption (excluding
milk), especially in premenopausal women. Furthermore, no
evidence is available justifying that milk consumption modi-
fies the prognosis of breast cancer patients (101).
As far as ovarian cancer is concerned, an analysis of the
original data from 12 cohort studies did not report significant
association with milk for a consumption of 500 g/d (RR ¼1.11,
95% CI 0.87–1.41) (102). Moreover, a recent Mendelian ran-
domization study did not identify differences in the risk of
ovarian cancer in relation to lactase persistence (the ability to
release galactose from lactose) or absence (where galactose is
not released from lactose) (103).
In conclusion, the available data suggest that milk con-
sumption is not associated with either risks or protective
effects on cancer incidence. A modest direct association
between milk consumption and incidence of prostate cancer
and an inverse correlation with colorectal cancer have been
reported. Milk consumption does not appear to affect the
risk of developing breast cancer or the evolution of the dis-
ease in affected women.
Conclusions
Cow’s milk (and dairy products), due to their composition,
can facilitate the appropriate intake of some important
macro- and micronutrients throughout life.
The available evidence from the scientific literature sug-
gests that the vast majority of associations between milk
consumption and health are favorable. This especially
applies to the early stages of life, where the relationship
between milk and dairy products consumption and bone
mass is evident.
There are neutral or favorable associations between milk
consumption and the risk of overweight, obesity, diabetes,
or cardiovascular disease (with a possible protective effect
on stroke risk).
Cancer risk does not appear to be affected by milk con-
sumption, with small effects—in opposite directions—for
colon and prostate cancers.
Milk, if consumed according to guidelines and within a
balanced diet, can continue to be part of human diet.
8 F. MARANGONI ET AL.
Conflicts of interest
All the authors have subscribed to a conflict of interest dec-
laration on the topic of this article. Andrea Poli and Franca
Marangoni are respectively president and responsible for
research of NFI, a nonprofit organization partially supported
by 18 food companies.
Carlo La Vecchia received funding from Soremartec Italia
s.r.l. for conferences and educational activities (not specific-
ally for the submitted work).
Maria Luisa Brandi received funding from Consorzio del
Formaggio Parmigiano Reggiano for conferences and educa-
tional activities (not specifically for the submitted work).
Funding
The symposium was independently led by NFI and sup-
ported by an unrestricted grant from Granarolo S.p.A.,
Parmalat S.p.A., Danone S.p.A., Nestl
e Italiana S.p.A., and
Soremartec Italia S.r.l. The sponsors had no role in planning
and organizing the symposium, in preparation of the article,
and in the decision to publish the document.
ORCID
Franca Marangoni http://orcid.org/0000-0003-3590-2330
Carlo La Vecchia http://orcid.org/0000-0003-1441-897X
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