- 1 Key messages
- 2 Rationale
- 3 Background
- 4 Views on dairy and calcium in the major cancer prevention reports
- 5 Epidemiological evidence
- 6 Potential mechanisms of action for cancer prevention
- 7 Potential mechanisms of action for cancer causation
- 8 Recommendations
- 9 Future research
- 10 Position statement details
- 11 References
Dairy foods provide the richest source of dietary calcium. Dairy foods contain a high calcium content per serve and this calcium is well absorbed by the body. Calcium from non-dairy sources is less concentrated, and therefore more of the food needs to be consumed to meet recommended levels[2, 3]. Dairy foods also provide significant amounts of other nutrients including protein, vitamin A, vitamin B12, magnesium, phosphorus, potassium, riboflavin and zinc. In addition, dairy products contain conjugated linoleic acid, butyric acid, sphingolipids and 13-methyl tetradecanoic acid which may have anti-cancer properties.
The role of dairy foods in bone health is well established. In addition to playing an important role in the prevention of osteoporosis, dairy foods are essential for good dental health. There is also some evidence that dairy foods may play a role in weight regulation, prevention of cardiovascular disease and in management of hypertension.
Unfortunately, there is a lot of misinformation regarding the relationship between dairy foods and cancer risk. It is important for Cancer Council to evaluate the association between dairy foods, calcium and cancer risk in order to develop clear messages and recommendations. Evidence for the role of dairy foods in cancer mostly relates to prostate, bowel and breast cancers, the most prevalent cancers in Australia, as well as ovarian cancer.
Dairy foods include foods such as milk, yoghurt, cheese, ice cream, butter, cream and fermented milk. Table 1 shows the calcium content of some common dairy foods.
Table 1. Average calcium content of dairy foods
|Food source||Serving size||Calcium per serve|
|Regular milk||250 mL||268 mg|
|Skim milk||250 mL||303 mg|
|Natural regular yoghurt||200 g||386 mg|
|Natural low fat yoghurt||200 g||488 mg|
|Cheddar cheese||40 g||305 mg|
|Ice cream (standard vanilla)||50 g||26 mg|
In addition to dairy foods, calcium-fortified food products are an increasingly common source of calcium in the food supply. Calcium-fortified foods include breakfast cereals (contain up to 268 mg of calcium per serving of 1 cup or 40 g); juice (up to 255 mg/250 mL); white bread (68 mg calcium/two slices or 30 g); and soy milk (298 mg/250 mL). Calcium-fortified cows milk contains 522 mg calcium per 250 mL serving.
According to the last National Nutrition Survey in 1995, dairy products were the second greatest contributor to energy intake for both men and women, accounting for about 11% of total energy intake. Dairy products also accounted for more than half the daily calcium intake, with 30–45% coming from milk, about 10% from cheese and about 5% from frozen milk products. The contribution of dairy products to children’s calcium intake was much greater than for adults.
Two and a half to four serves of dairy foods per day provide the recommended daily calcium intake for adults. The current Recommended Dietary Intake (RDI) for men is 1000 mg/day for those aged 19–70 years and 1300 mg/day for those aged over 70 years. For women, the RDI is 1000 mg/day for those aged 19–50 years and 1300 mg for those aged over 50 years (post menopausal). Increased calcium is not required for pregnant and lactating women over the age of 18[1, 9].
The upper dietary intake limit for calcium for adults has been proposed at 2500 mg/day. Toxic effects of calcium have only been seen when calcium is given as calcium carbonate in an antacid form. The resulting hypercalcaemia can cause renal calcification and renal failure.
In Australia, dietary calcium intakes are less than recommended. It is estimated that more than 25% of men and 50% of women have a calcium intake below the RDI. Of concern are those not receiving sufficient calcium during the years of bone modelling and those older Australians who are at risk of osteoporosis. Dairy foods provide a number of other important nutrients including protein, phosphorus, magnesium, potassium and zinc which are needed for bone development and maintenance. Vitamin D, which is found in small amounts in fortified dairy products (for Australians the main source of Vitamin D is from exposure to sunlight) plays an important role in maintaining bone health[10, 11].
Views on dairy and calcium in the major cancer prevention reports
In 2007, the World Cancer Research Fund found there was:
- probable evidence that milk reduced the risk of bowel cancer, and limited suggestive evidence that milk lowered the risk of bladder cancer
- limited suggestive evidence that milk and dairy foods increased the risk of prostate cancer and that cheese increased the risk of bowel cancer
- probable evidence that diets high in calcium increased the risk of prostate cancer and that calcium supplements lowered the risk of bowel cancer.
The World Health Organization concluded in 2003 that there was some evidence that bowel cancer risk was decreased by high intakes of calcium. This hypothesis however, has not been firmly established. Several observational studies have provided support for this theory, and two trials have indicated that supplemental calcium may have a modest protective effect on the recurrence of bowel adenomas.
Meta-analyses have consistently shown an association between dairy consumption and reduction in bowel cancer risk. Similarly, meta-analyses have demonstrated a link between calcium supplementation and reduction in bowel adenoma recurrence. Table 2 summarises the evidence for a link between dairy consumption and calcium supplementation with bowel cancer and adenoma risk.
A 2012 meta-analysis of 19 cohort studies found that milk and total dairy intake, but not cheese were associated with reduced bowel cancer risk. The study found the strongest effect was for total dairy. The summary relative risk (RR) per 400 g/day of total dairy products was 0.83 (95% confidence interval (CI)= 0.78-0.88). A smaller, but significant effect was seen for milk, (RR= 0.91, 95% CI= 0.85-0.94) per 200 g/day intake and no effect was seen for cheese (RR= 0.96, 95% CI= 0.83-1.12) per 50 g/day. These associations were restricted to colon cancer.
An earlier meta-analysis in 2009 of 60 observational studies similarly reported that both high milk and dairy intake were associated with a decreased risk of colon cancer. However, milk was found to have no association with rectal cancer risk. The analysis found that high calcium intake was also protective against bowel cancer, both in dietary and supplement form.
A pooled analysis of ten cohort studies in 2004 found that higher intakes of milk and calcium (from diet and supplements) were associated with a reduced risk of bowel cancer. While cheese intake tended to be weakly positively associated with bowel cancer risk, yoghurt had a weak inverse association, with neither result being statistically significant. Higher intakes of dietary and total calcium were associated with a significant lower risk of bowel cancer. This study estimated that up to 1000 mg/day of calcium is required to protect against bowel cancer.
A 2006 systematic review of 12 cohort studies found that nine studies did not show a significant relationship between milk consumption and risk of bowel cancer and two reported a protective effect for bowel and colon cancer. One study with a relatively small cohort (<10,000 participants) found a positive relationship between dairy foods and rectal cancer risk. One study found a borderline positive relationship in women between cheese intake and rectal cancer, while five studies showed no relationship between dairy products and bowel cancer. Overall, consumption of dairy products appears unrelated to colon cancer, although a harmful effect on rectal cancer risk cannot be excluded.
Two 2010 meta-analyses investigating bowel adenoma risk found that supplemental calcium was effective for the prevention of adenoma recurrence in populations with a history of adenomas, but not in other populations, and not for any other disease outcomes[18, 19]. Similarly, an earlier meta-analysis of three RCTs investigating the role of calcium supplementation in preventing colon adenoma recurrence showed a significantly decreased risk of recurrent adenoma in the group receiving calcium supplementation.
A 2008 Cochrane review of two double-blind, placebo-controlled RCTs suggested that for people with previous adenomas, calcium supplementation reduced the risk of recurrent bowel adenoma. The combined odds ratio for recurrent bowel adenoma for both studies was 0.74 (95% CI 0.58-0.95) for those receiving supplemental calcium.
Table 2. Summary of the association between dairy food consumption and bowel cancer risk
|Aune et al. (2012)||Bowel cancer||Total dairy||0.83||0.78-0.88|
|Cho et al. (2004)||Bowel cancer||Dietary calcium||0.86||0.78-0.95|
|Total calcium (dietary and supplemental)||0.78||0.69-0.88|
|Huncharek et al. (2009)||Colon cancer||All dairy||0.84||0.75-0.95|
|Carroll et al. (2010)||Bowel adenoma recurrence||Calcium supplement||0.80||0.69-0.94|
|Cooper et al. (2010)||Bowel adenoma recurrence||Calcium supplement||0.82||0.69-0.98|
|Shaukat et al. (2005)||Colon adenoma recurrence||Calcium supplement||0.80||0.68-0.93|
RR= relative risk, CI= confidence interval
A number of meta-analyses have investigated the link between dairy consumption and calcium intake, and prostate cancer. Over all, evidence suggests that high calcium is associated with increased prostate cancer risk, and there is some limited evidence for a link between dairy consumption and increased prostate cancer risk. Table 3 summarises the evidence for a link between both dairy and calcium.
A 2008 meta-analysis of 23 cohort studies, 26 case-control studies and one RCT investigated the link between dairy products and dietary calcium, and prostate cancer. Over all the meta-analysis found no evidence to support an increased risk of prostate cancer with calcium or dairy products. Analysis of cohort studies demonstrated no association between milk or dairy intake and prostate cancer. However, cohort studies analysing calcium intake and prostate cancer risk were heterogeneous and could not be combined. Similarly, case-control studies found no association between dairy or calcium intake and prostate cancer, but for milk intake were heterogeneous and could not be combined.
A 2007 meta-analysis of 13 cohort studies found that high consumption of milk and dairy products was associated with a higher risk of prostate cancer. Sub-analysis of the studies included also demonstrated an increased risk of prostate cancer with milk and cheese specifically.
Similarly, a 2005 meta-analysis of ten cohort studies found that men with the highest intake of dairy foods and calcium were significantly more likely to develop prostate cancer than men with the lowest intake. However this result was not significant when only those studies with a validated food frequency questionnaire and those that adjusted for energy intakes were considered. This meta-analysis was recently reviewed in response to criticism that it did not include data from the Melbourne Collaborative Cohort Study (MCCS). The MCCS is a large prospective study, which did not find any association between dairy products, butter, margarine and calcium intakes and the risk of prostate cancer. When the results of the MCCS were included in a meta-analysis the following year, the positive association between a high dairy intake and prostate cancer risk remained, but was no longer statistically significant. This positive association was also attenuated for high calcium intakes.
A 2004 meta-analysis evaluated the association between milk consumption and prostate cancer exclusively from case-control studies. A positive association between milk and dairy consumption and prostate cancer risk was found, however many of the studies were found to be subject to bias. In addition, eight of these studies used hospital-based controls, which may not be representative of the general population.
Table 3. Summary of the association between dairy food consumption and prostate cancer risk
|Huncharek et al. 2008||Dairy||1.06 (cohort studies)||0.92–1.22|
|1.14 (case-control studies)||1.00–1.29|
|Milk||1.06 (cohort studies)||0.91–1.23|
|Calcium||1.04 (case-control studies)||0.90–1.15|
|Qin et al. (2007)||Dairy products||1.13||1.02-1.24|
|Gao et al. (2006)||Dairy products||1.09||1.00-1.20|
|Gao et al. (2005)||Dairy products||1.11||1.00-1.22|
|Qin et al. (2004)||Milk||1.68||1.34-2.12|
|Milk and dairy products||1.61||1.22-2.12|
RR= relative risk, CI= confidence interval
Two 2011 meta-analyses have investigated the link between milk and dairy consumption and bladder cancer risk. One analysis of the link between milk consumption and bladder cancer risk included six cohort and 13 case-control studies. High milk intake was associated with decreased bladder cancer risk (odds ratio= 0.84, 95% C= 0.71-0.97). The association was higher in Asia than North America, and no association was seen in European populations.
The other analysis included six cohort and 12 case-control studies investigating the association between milk and dairy products, and bladder cancer. This analysis found a slight, but non-significant reduction in bladder cancer risk associated with high milk intake (RR= 0.89, 95% CI= 0.77-1.02). This association was significant only United States-based studies (RR= 0.88, 95% CI= 0.79-0.99). There was no over all association between total dairy consumption and bladder cancer risk (RR= 0.95, 95% CI= 0.71-1.27).
An early meta-analysis suggested there may link between dairy consumption and increased breast cancer risk. Subsequent studies reported inconsistent results on the association between dairy intake and breast cancer risk, until more recent studies reported a reduced risk of breast cancer associated with dairy and calcium intake. Table 4 summarises the evidence for a link between dairy consumption and breast cancer.
A 2011 meta-analysis analysed the association between dairy consumption and breast cancer risk in 18 cohort studies. The analysis found that increased consumption of total dairy was associated with decreased breast cancer risk. Milk consumption was associated with a non-significant decrease in breast cancer risk. Similarly, a 2010 meta-analysis of six cohort and nine case-control studies found evidence that high calcium intake was associated with a decreased risk of breast cancer. There was a significant amount of heterogeneity among the studies analysed in both meta-analyses[30, 31].
A 2009 report prepared for the Agency for Healthcare Research and Quality found that calcium intake in premenopausal women was associated with a decreased risk of breast cancer in four of the six cohort studies reviewed. The review found no association between calcium intake and beast cancer risk in postmenopausal women.
Older analyses have yielded inconsistent results on the association with dairy intake and breast cancer risk[33, 34]. A 2003 meta-analysis of 14 case-control and five cohort studies found the evidence to be inconsistent regarding milk consumption and breast cancer risk. The results suggested that high milk and cheese intake was associated with a non-significant increased risk of breast cancer. Similarly, a 2002 meta-analysis of eight prospective cohort studies did not find an association between milk products, dairy fluids or dairy solids and breast cancer risk. Cheese consumption was associated with a non-significant increase in breast cancer risk.
Conversely, a 1993 meta-analysis of 10 case-control and one cohort study on the association between cheese and milk intake and breast cancer risk suggested that higher intakes of milk and cheese were associated with a non-significant increase in breast cancer risk.
Table 4. Summary of the association between dairy food consumption and breast cancer risk
|Dong et al. (2011)||Total dairy||0.85||0.76-0.95|
|Chen et al. (2010)||Calcium (dietary and supplemental)||0.79||0.70-0.89|
|Boyd et al. (2003)||Milk||1.12||0.88-1.43|
|Missmer et al. (2002)||Total dairy fluids||0.99||0.97-1.00|
|Total dairy solids||1.03||0.95-1.11|
|Boyd et al. (1993)||Milk||1.22||0.91-1.64|
RR= relative risk, CI= confidence interval
Studies of the association between dairy consumption and ovarian cancer risk have generally yielded evidence of some link but at a statistically non-significant level. See Table 5 for a summary of the evidence of an association between dairy consumption and ovarian cancer risk.
Two 2006 analyses of dairy consumption and ovarian cancer risk found no statistically significant associations between dairy consumption and ovarian cancer risk[38, 39]. One meta-analysis of three cohort and 18 case-control studies found some that cohort studies tended to show that high intakes of dairy foods (at least four servings) may increase the risk of ovarian cancer, however these results were not significant. In a combined analysis of case controls and cohort studies, the consumption of dairy products, whole milk and yoghurt were positively but not significantly associated with a modest increased risk of ovarian cancer. The consumption of milk, skim milk, and cheese were inversely associated with ovarian cancer risk, but again the relationships were not significant. The other, a pooled analysis of 12 cohort studies found no statistically significant associations between the consumption of dairy foods, specifically milk, cheese, yoghurt and ice cream, dietary calcium intake and total calcium intake and the risk of ovarian cancer .
A 2005 meta-analysis pooled data from two cohort and 20 case-control studies, to evaluate the risk of ovarian cancer associated with milk and dairy product consumption. This meta-analysis found that the consumption of dairy products, whole milk and butter were associated, but not significantly, with increased risk of ovarian cancer. However, overall there was no association between milk and dairy product consumption and the risk of ovarian cancer. Further, a number of the analyses were based on a small number of studies, limiting validity.
Table 5. Summary of the association between dairy food consumption and ovarian cancer risk
|Genkinger et al. (2006)||Total milk||1.11||0.87-1.41|
|Larsson et al. (2006)||Dairy products||1.17||0.85-1.60|
|Skim/low fat milk||0.94||0.75-1.17|
|Qin et al. (2005)||Dairy products||1.25||0.76-2.08|
RR= relative risk, CI= confidence interval
Potential mechanisms of action for cancer prevention
According to the results of experimental studies, the presence of sphingolipids, calcium, conjugated linoleic acid, butyric acid and lactic acid bacteria in dairy products have the potential to reduce bowel cancer.
Sphingolipids are found in regular and reduced-fat dairy products. Evidence from animal studies suggests that sphingolipids suppress early markers of colon carcinogenesis and the appearance of advanced malignant tumours.
It has been proposed that ionised calcium or calcium phosphate may reduce colon cancer by binding secondary bile acids and free fatty acids to form insoluble soaps[41, 42]. These insoluble soaps therefore protect the epithelial cells of the colon from potential toxic affects of the bile and free fatty acids.
Butyric acid and conjugated linoleic acid may also play a role in protecting against colon cancer.
There are several mechanisms by which lactic acid bacteria may inhibit colon cancer. Such mechanisms include the binding/degrading of potential carcinogens; changes in the metabolic activities of the intestinal microflora; and the production of anti-mutagenic compounds or enhancement of the host’s immune response.
Experimental studies suggest that the presence of calcium, conjugated linoleic acid, butyric acid, branched long-chain fatty acids and milk proteins in dairy products have the potential to prevent breast cancer.
Calcium may neutralise fatty acids and mutagenic bile acids which pass from the intestine to the breast where they can affect oestrogen receptors. Animal studies provide evidence for anti-carcinogenic properties of calcium in the presence of vitamin D. Animals fed diets deficient in calcium and vitamin D develop mammary hyperplasia and hyperproliferation. In addition, supplementation with calcium and vitamin D protects against mammary tumours in rats fed a high fat diet or treated with a chemical carcinogen.
Conjugated linoleic acid refers to a mixture of positional and geometric isomers of linoleic acid which are found in dairy products and meat. Animal studies have indicated that conjugated linoleic acid may inhibit the growth and spread of mammary tumours, possibly in a dose response relationship. Epidemiology studies to date have provided inconsistent evidence. One study found no association between conjugated linoleic acid intake and the risk of breast cancer, another showed a weak positive association, and a third showed a 60% reduction in risk associated with higher intakes of conjugated linoleic acid.
Butyric acid and milk proteins may also have anti-carcinogenic properties. Butyric acid, present uniquely in milk fat, induces differentiation and apoptosis, and inhibits proliferation in experimental studies.
Branched-chain fatty acids are synthesised by rumen bacteria and are found in milk fat. 13-methyl-tetradecanoic acid has been found to induce cell death in human breast cancer cells by rapid induction of apoptosis.
It is thought that the vitamins found in milk have the potential to protect against ovarian cancer due to their antioxidant or anti-carcinogenic properties. Calcium may play a protective role by down-regulating the production of parathyroid hormone, which reduces mitosis and increases apoptosis.
Potential mechanisms of action for cancer causation
Previously it was believed that dietary fat played a role in the development of breast cancer, due to the strong correlation between per capita consumption of fat and breast cancer mortality in ecological studies, and because animal experiments showed that a high fat diet increased the incidence of chemically induced tumours. However with increased epidemiological data, there now appears to be little association between cancer in adults and total fat or type of fat. It is biologically plausible that fat may increase breast cancer risk from animal data. Potential mechanisms are thought to be through the development of free radicals, eicosanoids and mutagenic compounds from lipid peroxidation.
The incidence of breast cancer has declined in Israel since three pesticides, previously found in high concentrations in milk, were banned in the 1980s. This decline in breast cancer incidence provided evidence for the role of dairy food contaminants in the risk of breast cancer. Evidence since this time suggests that there is no association between organochlorine exposure and breast cancer. The 20th Australian Total Diet study 2003, formally the market basket survey, found no detection of pesticide residue in samples tested of cheddar cheese, whole milk and vanilla ice cream. The study concluded that dietary exposures to pesticide residues in Australia were all within acceptable health standards.
Insulin Like Growth Factor-I and Growth Hormone
Insulin Like Growth Factor-I (IGF-I) has been suggested as a link between dairy product consumption and breast cancer risk. However the amount of IGF-I consumed daily from milk products is minute compared with endogenous production. There is little evidence to suggest that there is significant absorption from dairy foods, as it is broken down in the gut. It appears that the evidence linking IGF-I in milk and breast cancer risk is weak.
The European Prospective Investigation into Cancer and Nutrition (EPIC) case-control study found that serum concentrations of IGF-I showed no associations with risk of bowel cancer. However, a meta-analysis of nine prospective studies, combined with EPIC data found a modest association between serum IGF-I and bowel cancer.
Bovine somatotrophin or growth hormone has been implicated in the development of breast cancer. In some countries growth hormone is administered to cows to increase milk production and it also increases milk IGF-I levels. However bovine somatotrophin has not been registered for use by the Australian Pesticides and Veterinary Medicines Authority for use in Australia. It is approved in the US and 24 other countries, but not approved for use in Australia, New Zealand, Canada or Europe.
Lactose and galactose
The earliest link between dairy consumption and increased ovarian cancer was attributed to the lactose content of dairy[53, 54]. Lactose is converted to glucose and galactose. It was suggested that galactose consumption coupled with a reduced ability to metabolise galactose in the ovary would result in ovarian toxicity. In addition to lactose, a high consumption of fat may also increase ovarian cancer risk through increased oestrogen levels, but this is inconclusive.
In terms of cancer risk, dairy foods and calcium have been reported as both protective and harmful. The evidence is not conclusive that dairy foods can protect against cancer, nor that they increase the risk. Overall the proven health benefits of dairy foods outweigh the unproven harms.
Dairy foods should be encouraged as part of a varied and nutritious diet as they are essential to maintain good bone and dental health. Cancer Council therefore supports the Australian Dietary Guidelines that encourage at least three serves of dairy foods (milk, cheese, yoghurt) each day.
Cancer Council also encourages people to choose reduced fat varieties of dairy foods where appropriate, as this will help to maintain a healthy body weight and reduce the total and saturated fat content of the diet. In addition, Cancer Council recommends that dairy foods such as cream and butter should be limited, as they contain a large amount of saturated fat.
Cancer Council does not support the use of calcium supplements for cancer prevention, but acknowledges that calcium supplementation provides an alternative source for people unable to consume enough dietary calcium (e.g. those who are lactose intolerant or who follow a strict vegan diet).
The relationship between dairy foods and cancer, particularly breast, prostate and ovarian cancer deserves further examination due to the inconsistencies that still exist in the literature. As with many other nutritional factors, there is a need for better quality, well-reported, larger studies that are of longer duration. Studies need to be performed in populations with sufficient variation in dairy food intake.
A better understanding is required of the calcium dose that would be both safe and effective in reducing cancer risk, particularly for prostate and bowel cancer. This requires appropriately designed randomised controlled trials before new public health recommendations regarding the optimal dose and duration of calcium supplementation can be made.
In addition, the protective constituents of dairy foods need to be identified to better understand the protective role of dairy foods, and the literature regarding probiotics and their role in cancer prevention, particularly colon cancer needs to be evaluated.
Position statement details
This position statement was reviewed and approved by the Public Health Committee May 2007 and updated January 2013.
This position statement has been reviewed by:
- Caryl Nowson
- Jacinta Orr
- Andrew Penman
- Monica Robotin
- Carla Saunders
- Hayley Ralph
- Craig Sinclair
- Lucy Smith
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