The Mediterranean diet (MedDiet) has long been celebrated for its health benefits, including a reduced risk of cardiovascular diseases, type 2 diabetes, cancer, inflammation, fractures, and neurodegenerative disorders. A key component of this diet, often overlooked, is the inclusion of fermented dairy products (FDP) such as yogurt and cheese. These foods, consumed for thousands of years, not only enhance the preservation, transportability, and digestibility of milk but also contribute significantly to the diet's overall health benefits.
The Role of Fermented Dairy in the Mediterranean Diet
Fermented dairy products have been a staple in diets for millennia, dating back to the sixth millennium BC in Northern Europe. The fermentation process breaks down lactose, making milk more digestible. In the Mediterranean region, milk from various animals like goats, sheep, and donkeys is commonly used, alongside cow's milk. These FDPs are rich in essential metabolites, bioactive compounds, vitamins, and minerals, making them valuable components of the MedDiet.
Nutritional Composition of Fermented Dairy Products
Fermented dairy products like yogurt and cheese are nutritional powerhouses, providing calcium, phosphorus, fat, carbohydrates, and protein. These nutrients play vital roles in various bodily systems, including bone health, cardiovascular function, intermediary metabolism, cancer prevention, central nervous system function, and inflammation modulation. Furthermore, they contain prebiotics and probiotics, which can modify microbiota composition and metabolism, indirectly influencing these systems.
Impact on Bone Health
Studies suggest that FDPs contribute to bone health. A meta-analysis of observational studies showed a positive linear relationship between adherence to a MedDiet and bone mineral density (BMD). In adults, consumption of fermented dairy products attenuates age-related bone loss. In a cross-sectional study of older adults, yogurt ingestion was associated with higher bone mineral mass and better muscle function. The risk of osteoporosis was significantly lower in those consuming one serving of yogurt per day.
Short-term intervention trials have shown that yogurt or cheese consumption can reduce parathyroid hormone (PTH) levels and biochemical markers of bone resorption without affecting bone formation markers. Consumption of vitamin D and calcium-fortified soft cheese by postmenopausal women reduced bone resorption biomarkers and increased serum IGF-I, indicating a reduction in postmenopausal bone turnover rate. Similar findings were observed in elderly women consuming soft cheese or yogurt.
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Long-term studies further support these findings. A 20-year follow-up of women revealed a reduced risk of hip fracture among consumers of yogurts, fermented milk, and cheese. Several meta-analyses have also confirmed that yogurt consumption is associated with a reduction in hip fracture risk.
Cardiovascular Benefits
The Mediterranean diet is known for its cardiovascular benefits. Adherence to a MedDiet is associated with a reduction in mortality or incident cardiovascular disease. While some guidelines recommend low-fat dairy products to prevent cardiovascular disorders, a large prospective cohort study found that greater dairy consumption was associated with a lower risk of cardiovascular disease and mortality.
Specifically, FDPs have shown promising results. A dose-response meta-analysis of prospective cohort studies indicated a reduction in cardiovascular disease and all-cause mortality with increased intake of cheese, sour milk, or yogurt. Increased consumption of yogurt and cheese was associated with reduced risk, while total dairy was not. Replacing milk with whole-fat yogurt products or cheese reduced myocardial infarction risk.
The "matrix effect" of dairies may explain these benefits. A randomized controlled trial found that cheese consumption reduced total cholesterol and LDL levels, while butter consumption did not. Supplementing a MedDiet with additional dairy foods resulted in decreased blood pressure, increased HDL cholesterol, and decreased triglycerides. Long-term follow-up studies have shown that yogurt and cheese consumption are associated with a reduced risk of incident high blood pressure.
Role in Type 2 Diabetes Prevention and Management
The MedDiet offers significant benefits for patients with type 2 diabetes (T2D). Studies have shown that increasing yogurt intake is associated with a lower risk of T2D. In the Women Health Initiative study, low-fat dairy product intake was inversely correlated with the risk of T2D, with high yogurt consumption associated with a lower risk.
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The Malmö Diet and Cancer Cohort study showed a reduction in T2D risk in subjects consuming higher amounts of total, non-low fat dairy. Decreasing total dairy intake led to a higher risk of T2D, while increasing yogurt consumption was associated with a lower risk. Numerous systematic reviews and meta-analyses have concluded that increasing yogurt intake is associated with a lower risk of T2D.
Cancer Prevention
The MedDiet has been linked to a reduced risk of various types of cancer. A meta-analysis demonstrated a reduction in cancer mortality and all-cause mortality among cancer survivors. In the Italian part of the EPIC study, yogurt consumption was associated with a lower risk of colo-rectal cancer.
Cognitive Function
Studies suggest that FDP intakes may be favorable for cognitive function. Higher adherence to the MedDiet was associated with a reduced risk of mild cognitive impairment (MCI) and Alzheimer’s disease (AD). Brain activity has been shown to be modulated by FDP. A study found that yogurt containing probiotics changed activity in brain regions controlling emotion and sensation.
Gut Microbiota Modulation
The gut microbiota (GM) plays a crucial role in human health. Some studies suggest that a MedDiet can modulate GM composition and function. Prebiotics, found in some FDPs, stimulate the growth and activity of beneficial bacteria in the large bowel.
Practical Integration of Milk and Fermented Dairy into the Mediterranean Diet
Integrating milk and fermented dairy into the Mediterranean diet involves mindful choices. Opt for less processed dairy products such as Parmesan, feta, or part-skim mozzarella, and choose plain Greek yogurt instead of high-sugar flavored varieties. While cow's milk can be a nutritious option, it's recommended to limit intake to a few times per week.
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For those who are lactose intolerant or prefer dairy-free options, alternatives like almond milk, soy milk, and oat milk can be incorporated. These dairy-free alternatives are often fortified with calcium, vitamin D, and other nutrients, making them a nutritious choice.
When planning meals, consider incorporating FDPs into breakfasts, lunches, dinners, and snacks. For example, Greek yogurt topped with fruit and nuts makes a nutritious breakfast, while feta cheese can be added to salads for lunch.
Serving Recommendations and Tips
- Dairy: No more than once daily (fewer may be better). Choose naturally low-fat cheese; Choose fat-free or 1% milk, yogurt and cottage cheese; Avoid whole-fat milk, cream, and cream-based sauces and dressings. Serving Size: 1 cup milk or yogurt; 1 ½ ounces natural cheese.
- Yogurt: Choose plain, unsweetened yogurt and add real fruits or a drizzle of honey or maple syrup if desired. Greek yogurt is a great choice due to its higher protein content and thicker texture.
- Cheese: Opt for unprocessed cheeses like feta, goat cheese, Parmesan, mozzarella, and ricotta. Limit intake of highly-processed cheeses like American or Velveeta.
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