Dairy foods provide important nutrients — such as calcium, vitamin A, vitamin D, and protein. While you can get calcium and the other nutrients from non-dairy food sources, the USDA continues to recommend that Americans (age 9 and over) consume a recommended 3 cups/day of any low-fat dairy products (assuming a 2,000 calorie day), stating in the 2020-25 Dietary Guidelines for Americans that other products sold as “’milks” but made from plants (e.g., almond, rice, coconut, oat, and hemp “milks”) are not included as part of “the dairy group” because their overall nutritional content is not similar to dairy milk and fortified soy beverages. Most other major medical organizations also continue to recommend dairy foods for their nutrient density, including groups, e.g., the American Diabetes Association (ADA), addressing those at risk for or currently diagnosed with diabetes. So, what’s the deal with diary and diabetes?
Many of the leading medical groups continue to debate whether low-fat dairy is superior to, equivalent to, or possibly less beneficial than higher-fat types. That’s but one of the tricky questions about dairy consumption that remain just that: questions — with many different answers — whether it be for individuals with or at risk for diabetes or for the general public. Among the other, many debated issues around diary and diabetes, some of the most important that we’ll explore in this report include:
- Can dairy foods help reduce the risk of type 2 diabetes (T2D), or help to better manage the disorder?
- How much dairy should those at risk for or with diabetes optimally consume each day?
- Will consuming more dairy foods help or hurt weight management efforts?
- Must those dairy foods be low-fat, so as to prevent increased cardiovascular risks? Or are higher-fat kinds OK or even preferable?
- What types of dairy food confer the most benefits, and is yogurt unique among dairy choices for its significant health benefits?
What does the ADA recommend “overall” for daily nutrition, and for dairy?
Before and as we explore these pressing questions about dairy and diabetes, it’s important for context to understand the ADA’s position (in the 2022 Standards of Care in Diabetes) about overall nutritional therapy: “There is no macronutrient pattern for people with diabetes.” Rather, ADA thinks that “meal plans should be individualized while keeping total calorie and metabolic goals in mind.” This philosophy embraces what medical researchers have found studying T2D: “The pathophysiology of type 2 diabetes (T2D) is complex and not the same for each individual” (2019 clinical review).
Dairy as a carbohydrate
The ADA’s stance on diary and diabetes is significant because, unlike the USDA, ADA doesn’t identify dairy foods as a separate, key food group. Rather, ADA references dairy as but one example of a carbohydrate food that those with diabetes can choose, assuming the dairy contains minimal sugars, along with other nutrient-dense carbohydrate sources that are high in fiber (at least 14 g fiber per 1,000 kcal) and minimally processed — especially nonstarchy vegetables, fruits, and whole grains. This placement by ADA of dairy within the carbohydrate section of its summary recommendations is interesting, since clearly dairy foods also contain (and can be high in) protein and fat, and often that fat is saturated fat (dairy being an animal-derived food group). But the carbohydrate component of dairy is also significant, and especially relevant for those with diabetes, as carbs can both impact blood glucose unfavorably (i.e., make it rise) while too many carbs can also contribute to weight gain — two major issues for those with diabetes. (Learn more: Confused About Carbohydrates?)
Accordingly, ADA continues to recommend reducing overall carbohydrate intake for individuals with diabetes. The implication: dairy products should be consumed in moderation if carb intake in other carb categories is trending high.
Saturated fats are an issue — but ADA looks at them in total, not in dairy alone
The ADA is also keenly focused on cardiovascular risks, which are such a big issue for those with diabetes. So it’s no wonder that they recommend capping the daily total intake of saturated fats, which are linked to higher LDL (the “bad” cholesterol) and increased incidence of cardiovascular disease (CVD). Concurrently, ADA recommends the increased consumption of healthier unsaturated and polyunsaturated fats. However, the ADA does not reference dairy foods in its fats summary discussion, even though many dairy foods contain significant amounts of saturated fats. ADA makes reference to one (and only one) diet by name, the Mediterranean diet, citing that diet’s abundance of “good fats” such as olive oil and fatty fish. Interestingly, though, and not mentioned by ADA: dairy consumption is significantly lower in most Mediterranean diets than it is in the average U.S. diet.
Food is a matrix … which also makes it so hard to study
That the ADA refrains from further details concerning consumption of dairy foods in its summary recommendations is probably an indication of their belief, a medically sound one, that it’s the foods that you eat, in total — taking into account the combinations of different types and quantities of foods you eat per meal and per day — that matters much more than the individual nutrients you consume. A single-nutrient focus might work well for prevention of deficiency diseases, such as scurvy or beriberi, but this approach generally fails for chronic diseases such as coronary artery disease (CAD), stroke, type 2 diabetes (T2D), or obesity. For such complex conditions, the focus needs to be on foods and meals, and foods represent complex matrices of nutrients, minerals, bioactives, food structures, and other factors (e.g., phoshopholipids, prebiotics, probiotics) with correspondingly complex effects on health and disease. As one scientist aptly stated in a 2020 study, “the health effects of foods cannot be predicted by their content in any nutrient group without considering the overall macronutrient distribution.” Some researchers are calling this overall food distribution the “food matrix,” and the importance of this concept cannot be denied.
The dilemma: How do you value dairy, and its many types, within a much larger food matrix?
Unfortunately, studying food consumption in totality, as a matrix, is even more challenging than studying individual nutrients, which as we mentioned is flawed simply because we know people don’t eat one nutrient or even one food at a time. We’ll touch more on this research dilemma as we talk about recent studies and findings relating to the very complex food subgroup, dairy foods.
Diary and diabetes: How much dairy is optimal?
As we mentioned at the outset, the USDA recommends that the average American consume 3 cups of dairy per day, assuming a total calorie intake of 2,000 calories in the day, and they suggest that fat-free or low-fat forms are preferable. They warn that about 90 percent of the U.S. population does not meet this dairy recommendation. USDA does not specify or favor particular types of dairy (e.g., yogurt, cheese, milk).
By contrast, as we indicated above, the ADA doesn’t specify a recommended amount of dairy for those with diabetes; instead, ADA says the focus should be on total calories and total carbs (including dairy), all the while watching out for bad fats (including certain dairy foods). So ADA’s is a general yet individualized total food consumption recommendation. Translation: It’s OK to eat dairy if you have diabetes, but watch out if you eat so much that it brings your total calorie or carb count up too high. And curb your higher-fat dairy consumption if you think your total saturated fats consumption, from that dairy and the other foods you like to eat, is getting near excessive levels.
Can dairy foods help reduce the risk of type 2 diabetes (T2D)?
So what if you don’t have diabetes, but are at risk for it? We know that 96 million Americans clearly are, because they’ve already been diagnosed with prediabetes (CDC data). And many more of us are probably near the prediabetes level. Will dairy consumption help prevent or add to your risk of developing T2D? The answer is a tentative “Yes”: dairy may reduce T2D risk modestly; but the research findings still have many inconsistencies, and not all studies separate out the impact of low-fat dairy options compared with higher-fat types. Another reason for the inconsistent findings is that, as one leading scientist aptly put it, “The pathophysiology of T2D is complex and not the same for each individual.”
A 2019 clinical review that assessed all available evidence (to that date) from large prospective cohort studies and limited randomized controlled trials (RCTs) concluded that total dairy consumption has a neutral or moderately beneficial effect on T2D risk. This same review concluded that yogurt is most strongly associated with a lower T2D risk, although they admitted that evidence from RCTs (randomized controlled trials) is scarce. Milk appeared minimally beneficial (but neither is it harmful). Results with cheese were mixed: many studies showed no association, some showed reduced T2D with higher cheese consumption. Butter and cream were found to add to risk, but the studies were either too small, too few, or not well designed, leading the authors to insist that much more research is needed before conclusions can be formed regarding those subgroups.
Several very large epidemiological studies have also found that higher dairy consumption correlates with lower risk of developing T2D, including a 2022 study from Korea, which showed that yogurt and cheese were the most beneficial; however, in women, only yogurt showed significant benefit. Similarly, the 2020 PURE study showed reduced incidence of T2D (and also reduced hypertension) with increased dairy consumption, but only with whole-fat (but not low-fat) dairy; (see our later section on the ongoing low-fat vs. fat dairy controversy). Bear in mind that epidemiological studies, although they examine a large number of people over many years, typically rely on questionnaires about food consumption, so these studies are not controlled nor randomized.
A 2021 prospective cohort study of subjects with prediabetes did find lower T2D incidence after increased consumption of low-fat dairy (milk or yogurt), but found that T2D incidence rose in a group consuming cheese.
An important, just published 2022 JAMA study, a systematic review of 28 dose-response meta-analyses to date, examined the evidence concerning all foods and all nutrients to assess their association with both diabetes and cardiovascular incidence. Interestingly, the only dairy product associated with protective abilities against diabetes was yogurt. Eggs, cheese and milk either had null impact, or authors stated that there were too few or inferior-designed studies to make any conclusions. A very large 2019 study (epidemiological) also that found that yogurt consumption resulted in 13% lower T2D incidence, making yogurt the most beneficial of the diary products they studied; cheese increased T2D risk, but when low-fat milk was substituted for the cheese, T2D risk was reduced, albeit slightly. The 2019 EPIC Interact study in Europe found that milk had no association with diabetes risk.
Understand that “no association” isn’t necessarily a bad thing. In other words, yogurt may exert substantial “protective” properties, meaning that yogurt consumption may significantly reduce the risk of T2D. The inconsistent findings regarding milk, on the other hand, may simply mean that its effects are “neutral,” if you will; so, if milk is a part of your diet because it’s very nutrient-rich (a great source of calcium and other nutrients), but doesn’t add to T2D risk, it may still have a very valuable place in your diet.
In conclusion, it is generally believed that total dairy intake does not add to T2D risk and may reduce its incidence modestly. Yogurt consumption appears to reduce T2D risk significantly, while the association between the other dairy subgroups and T2D seems minimal or unclear, in part because of conflicting study designs and results and different use of higher-fat vs. low-fat dairy products.
The low-fat vs. whole fat dairy controversy
Debate continues over whether the saturated fats in higher-fat dairy products (like whole milk, some yogurts, cheeses) are actually as bad for you as, say, the saturated fats in processed meats — or, are some saturated fats less evil than others?
As an example of the continued polarized views, the Mayo Clinic — which does advise consumption of dairy foods because their nutrient profile protects against bone loss — asks that those with diabetes avoid high-fat dairy products because of the saturated fats and cholesterol they contain, both of which they state increase your risk of heart disease and stroke. By contrast, the Cleveland Clinic, although it shys away from recommending whole milk for adults, admits that “the jury is still out” as to whether low-fat milk does a better job of protecting us against diabetes than whole milk — citing two studies: a 2018 study that concluded whole milk actually increases HDL (the good cholesterol) while having no different impact than low-fat milk on measures of total cholesterol, LDL cholesterol, insulin or glucose concentrations; and a 2016 cohort study that measured circulating blood biomarkers, which found that higher consumption of dairy fat actually lowered T2D incidence modestly.
A 2019 clinical review found that “very little evidence exists on the adverse impact of high-fat compared with low-fat dairy consumption on T2D risk,” and a 2020 study makes a similar case, suggesting that while “in some high-fat dairy products, the high lipid composition may offset the potential protective benefits of dairy ingredients, the medium-chain unsaturated fatty acids in milk and other dairy products may have a positive effect on reducing the risk of T2D.” Similarly, a 2019 case-cohort study opines that certain dairy products may have “protective components” such as whey proteins, odd-chain fatty acids, and the high nutrient density of dairy, and/or that “interactions within the dairy food matrix may modify the metabolic effects of dairy consumption.”
A 2019 European narrative review forms this conclusion: “Most of the meta-analyses and systematic reviews of the cohort studies point to a reduced risk of T2D with dairy intake of 3 servings per day. This effect was mainly attributed to low-fat dairy, particularly yogurt and cheese. However, there is no evidence in cohort studies that high-fat dairy intake poses any harm.
Also compelling, a 2020 review in the Journal of Cardiology, which concluded that “several foods relatively rich in saturated fatty acids (SFAs), such as whole-fat dairy…are not associated with increased CVD or diabetes risk.” The authors went on to argue that while “SFAs increase low-density lipoprotein (LDL) cholesterol, in most individuals, this is not due to increasing levels of small, dense LDL particles, but rather larger LDL particles, which are much less strongly related to CVD risk.” And, like other scientists in recent years, these authors insist that “the health effects of foods cannot be predicted by their content in any nutrient group without considering the overall macronutrient distribution.” Regarding yogurt and cheese, specifically, these authors state that “food-based meta-analyses consistently find that cheese and yogurt intakes are inversely associated with CVD risk, and that whole-fat dairy may also be protective against type 2 diabetes.”
Despite all this mounting research suggesting that dairy fat has fewer negative cardiovascular and metabolic effects than previously assumed, the American Heart Association continues to recommend only low-fat dairy foods and avoidance of all foods high in saturated fats, including butter, cheese, red meat and tropical oils. (But is it intentional that AHA leaves milk off of this “culprit list”?) AHA goes on to state that “decades of sound science has proven [saturated fats] can raise your “bad” (LDL) cholesterol and put you at higher risk for heart disease,” although they conclude by saying this:
“The more important thing to remember is the overall dietary picture. Saturated fats are just one piece of the puzzle. In general, you can’t go wrong eating more fruits, vegetables and whole grains – and taking in fewer calories.”
So what’s the best interim conclusion on this dairy fat vs. low-fat controversy? Perhaps the authors of a 2019 JAMA review and meta-analysis, which centered on plant-based foods as the best way to reduce T2D risk, formed the most sensible conclusion: it’s probably fine “to add some animal foods like dairy and chicken, etc. — as the Mediterranean and DASH diets do.” Similarly, the recent EAT-Lancet commission report noted that modest consumption of poultry, fish, and dairy in the context of a predominantly plant-based diet is unlikely to result in adverse health consequences.
Will eating more dairy help or hurt my weight management efforts?
Most studies show that moderate consumption of dairy foods can help you manage your weight, and getting and keeping your weight in a healthy range is of paramount importance for preventing as well as optimally managing diabetes.
In a 2016 meta-analysis, increased consumption of total dairy and milk alone were both associated with a decreased risk of obesity. Similarly, a 2016 prospective cohort study found that a greater intake of dairy foods was associated with less weight gain; but, interestingly, only high-fat dairy products (and not low-fat dairy products) were associated with less weight gain.
As a 2019 meta-analysis noted, dairy may only have an additive (positive) effect on weight loss when an individual adheres to an overall energy-restricted (total calories) diet. Dairy foods, with their protein and fat content, can, it’s theorized, help induce a feeling of fullness and reduced hunger, which might contribute to easier avoidance of more calorically-high and nutrient-weak carbohydrates, such as cookies and other highly-processed foods that contain added sugars and saturated fats. Even in Scandinavia, where “the Nordic diet” includes a low quantity of daily dairy, one study there found that it was the foods subjects avoided (hamburgers, sausages, pizza) when they were asked to consume more dairy that helped their T2D risk drop; another Nordic study from 2018 found that adding dairy products to a diet otherwise nearly void of them resulted in a lower prevalence of obesity (as well as LDL levels and blood pressure) in patients with T2D.
Diary and diabetes: the special case for yogurt
In light of so many recent findings (such as the aforementioned 2019 clinical review, 2019 European narrative review, 2021 prospective cohort study and 2022 JAMA study) that show evidence of significant health benefits from consumption of yogurt, we do believe that a strong case can be made for upping consumption of this dairy product, whether you have diabetes or not. As we discussed in Yogurt for Diabetics: Real vs. Unproven Benefits, studies do show that yogurt, even if it’s just because it’s a food that is relatively high in protein and low in sugar, can help you feel fuller and stave off hunger, making it a great food option if you’re focusing on managing your weight — which in turn tends to benefit your blood glucose stability.
It remains debated which other characteristics of yogurt make it healthy. For example, the value of yogurt’s probiotic features have been disputed by some scientists, such as in a 2019 meta-analysis which failed to demonstrate the benefits of consuming probiotic compared with conventional yogurt for improving glucose control in patients with diabetes or obesity. However, a 2022 study asserts that that earlier meta-analysis was limited by “the lack of examination of the effect of fermented dairy consumption on diabetes prevention.” Authors of the recent study conclude instead that “prospective cohort studies exploring the association between yogurt and T2D have consistently found a protective effect of yogurt consumption against the development of prediabetes and T2D.”
The decision about diary and diabetes, and whether to include dairy products in your diet, truly boils down to your preferences and what works for your body. If you are at risk for or have diabetes, the 2022 JAMA study and other new research largely supports what the ADA has already been saying: that fruits, vegetables, whole grains, and fiber are the most protective against the risk of adverse cardiometabolic outcomes, while red meat and sugar-sweetened beverages (SSBs) are the most harmful. Amongst various types of dairy foods, all of which are nutrient rich (and particularly high in calcium), yogurt appears particularly beneficial, even if the exact mechanisms continue to be debated. As for other dairy products, most seem slightly to moderately beneficial relative to cardiometabolic outcomes — assuming the overall diet is healthy and balanced, calorie-restricted, relatively low-carb overall and containing only low amounts of processed carb foods containing added sugars and fats. While the low-fat vs. higher-fat dairy argument is likely to continue for a while, based on current evidence, allowing yourself to consume some higher-fat dairy items, in small portions, is unlikely to prove highly detrimental, as long as your total daily intake of saturated fats does not exceed recommended levels because of that dairy component.