#575: How Does Dairy Impact Cardiometabolic Health? – Prof. Jean-Philippe Drouin-Chartier

Hello, and welcome to Sigma Nutrition Radio. This is episode 575 of the podcast. My name is Danny Lennon. You are very welcome to the show. Today, we're going to be taking a look at some of the research relating to dairy consumption and cardiomyobolic disease risk. And to go through this, I'm going to be talking with Professor Jean-Philippe Druin Chartier, who is an assistant professor at the Faculty of Pharmacy at Laval University in Canada, as well as being a registered dietitian. In addition to his PhD from Laval University, he went on to complete postdoc training at the Harvard School of Public Health. He conducts multidisciplinary research that integrates clinical trials, epidemiology and metabolomics all to try and understand how both diet, including what we'll talk about with dairy consumption today, as well as medication can interplay to prevent and manage cardiomyobolic diseases, so things like type two diabetes, hypertension, cardiovascular disease. So today, we're going to be looking at a number of his publications relating to dairy consumption, as well as the wider literature, to get a handle on how dairy may impact risk of different things like hypertension or type two diabetes, what the evidence might say, differences we might see between different types of dairy products, how we can think about this area of research more broadly and then come to some useful conclusions. So if you are interested in getting a set of detailed study notes to accompany this episode, remember, you can do so by being a Sigma Nutrition Premium subscriber. All those details will be linked in the description box where you're currently listening. In the description box, I'll also put a link to the studies that we discussed throughout this particular episode if you do want to go and read the full text of those. And in addition, those of you listening on the premium feed of the podcast will get our key ideas round up after the interview finishes. So that is it. I will get straight to this discussion between myself and Professor Jean-Philippe Rouen-Chapier. A very big welcome to the podcast. Jean-Philippe, thank you so much for taking the time to come and join me today. Yeah, thank you for the invitation. I have lots of things that I'm really intrigued to ask you about today. Before we get into any of the topic for today, I'd love if you could give people a bit of an introduction to your academic background, your current research interests and anything else that you think might be relevant for today's discussion. Yeah, so I'm primarily trained in nutrition. So I have a bachelor degree in human nutrition. I also have a registered dietitian title in Quebec, Canada. After completing my bachelor, I went to graduate studies in nutrition and experimental medicine. When I come to the series of studies on that, I always focus on cardiometabolic health, lipids, metabolism, blood pressure, control with the dietary interventions, like dairy, milk, and also studies on like other like type of fats on cardiometabolic health risk factors. I was trained here at the University at the Nutrition Research Centre, where there is a very large clinical researcher facility, one of the largest in Canada. So that gave us the capability to do some very highly controlled nutrition trial on dairy or other things. And in parallel, I also conducted a few epidemiological work like systematic reviews of prospective cohorts, during my PhDs, also on dairy and health. In many, 18, 19, I went to the Harvard School of Public Health for a postdoctoral fellowship, where I did additional epidemiological work on dairy and cardiometabolic health, but other foods like red meat, processed food, eggs. I wanted to do other things that just dairy, dairy, my postdoc. We also did some metabolomics in relationship with the cardiometabolic health. And since 2020, I'm back in Quebec at La Valle University as a as a professor. My research is again, keep the focus on cardiometabolic health. Still have an arm strongly on nutrition and cardiometabolic health, still doing work on dairy, but I think to integrate more work about the relationship between diet and medication use in the era of semagglutide. I am the impact of these new GLP1 drugs on diet and how diet influence the response of these drugs. So that's where we are right now in my research group. To start, I did want to mention and get into some of your work around dairy and cardiometabolic health, because I've been able to go through a number of your publications that have been very impressive, that I've spanned across a number of different outcomes. And as we'll get to this term, cardiometabolic health can be we have to look at different outcomes and how that specifically relates to the question we're asking. But also, I'd love for you to maybe highlight for people when we're thinking about the health impacts of dairy. We're obviously talking about a huge group here. And it's really an umbrella term for many different things that ultimately is going to really impact what questions we might find. So for you, could you maybe speak to this idea of why it's so important when we're trying to get answers to these questions that we do differentiate between different types of dairy, not only different types of products, but maybe the fat content, whether it's liquid, etc. Can you maybe speak to your thinking behind this? Yeah, so typically when we study dairy products, we study milk, cheese, yogurt, this can also include kefir, other fermented milks. And then the more process, should we really like ice cream. But typically, like if you do a survey of dairy intake or in most epidemiological studies, when we study total dairy intake, it will be mainly milk, then cheese and yogurt, like in order of intake. And then the others are very less consumed on a daily basis. And then in dairy, there is also the fat also kind of influence the classification. So typically, we usually can usually treat as an exporter like the ice or dairy, low fat dairy, for me, these terminology is not the more I tend to work in the fields. It's typically these are the terminology that I tend to avoid because what is low fat, what is ice fat, where is the threshold. So you because it can create some kind of confusion, I think, in the data. When you look at all that milk, 3% about 3.5, 3.25, depending where you are in the world, can be considered as a high shot dairy, but cheese is typically 35, 40% fat. So all milk will remain low fat relative to cheese. And even a low fat cheese or reduced cheese at 18% will be much higher in fat. So I tend to use like, I prefer like the whole fat, like how it is, like I'm in another fashion financing, and then the reduce where we can reduce or remove some fat from this. And the other type of typical less education for the dairy foods are is the fermentation. So is it a fermented one or not? So typically, we can ask non-fermented milk, extender milk, and then cheese and yogurt could be combined in this kind of exposure, depending on the type of cheese. Because both cheese and yogurt will have some kind of fermentation during the preparation of these dairy foods and depends on the type of cheese. But that these are the typical categories of dairy foods under this big umbrella. So there are many smaller umbrella, and then we can get to the food level. And I think that the more and more we see some data, especially on cardametabolic health, for me, the most important exposure will be the food itself. Milk, cheese or yogurt, because we see very different association with cardametabolic outcome, like type two diabetes between milk, cheese and yogurt. And when we do the total dairy X position, as the sum of all this can get the association will inevitably be confused by the association between each of the dairy food and the outcome. So for me, I think the best is to study milk, cheese and yogurt separately. And then there is some interest for the total intake approach. But really, the food is the most important because a different terms of matrix, fermentation, fat, they are all from cows, but it kind of really different for me. I think that's crucial. And I think for people listening, this will probably come up a number of times as we go through some of this work. But also it's important to distinguish at the food level, because that's really what people are consuming. And they use each of those foods in very different ways. They're not going to use milk and yogurt and cheese as the same ingredient in different meals, it's completely different. And so this is ultimately what we care about. So maybe we can start by talking about this outcome of type two diabetes because you've done some really nice work in this area. I think one of the original analyses of yours I came across was on these various large cohorts looking at these different dairy products and risk of type two diabetes. Can you maybe give us an overview of some of the findings not only from your analysis, but maybe how that matches up elsewhere, but particularly focusing on some of your work in this area related to type two diabetes specifically? Yeah, for type two diabetes, I would say my first work on this was in 2016 when we published a systematic review of metanalyzes. It's in today's technologies more of a number of the review, which was not what she was as a term in 2016. So it's a systematic review of metanalyzes. And we look at different outcomes, including type two diabetes. We listed all metanalyzes that were published so far. And in all of these, or most of all of these, yogurt was associated with the lower risk of type two diabetes, which was not as consistent when we were looking at milk and cheese. So the association between yogurt and type two diabetes has been known and documented for 15 years now. Then, when I was in the Albert School of Public Health, conducted a very interesting analysis leveraging the nurse's health study, one and two, and the L-professional follow-up study, which are very large cohorts of some of the largest in the U.S. and the Worm, with repeated diet data over multiple decades. Nurse's health studies and L-professional follow-up study, they all started like early eighties-ish. And every four years, the participants, these three cohorts totaled about 200,000 individuals, they completed the food-frequency questionnaire. So with this, we could calculate change in intake of dairy and in relationship with type two diabetes incidents. So that's a very unique design that can only be tested in cohorts with repeated diet data, which these cohorts have. And we, again, we found that individual over a four-year period, when they increased their yogurt consumption, they had a lot of risk of type two diabetes. When the consumption was reduced, the risk was slightly higher. And these associations were not as clear for milk and cheese. And then, many other studies that reported on yogurt and type two diabetes. That's really useful. And so from there, I suppose, the question that might be coming to people listening now is what is it that we suspect may be going on? Or what are some of those mechanisms that would lead to higher intakes of yogurt leading to this potential risk reduction? Yeah, that's a big question. We can look at yogurt first as a different food than cheese and milk. So relative to milk, yogurt is fermented. So it will contain some bacteria that are known to be beneficial for gut microbiota, and that could translate, maybe in the long term, on improved cardio-metabolic. So in some animal studies, there are some data showing that this kind of bacteria is beneficial for the cardio-metabolic. Yogurt is also usually lower fat, but can contain some fat. Usually one to three percent, similar to milk for most, for the yogurts that are not the most consumed. So that could be part of it. Which will differ from a cheese, which is more on the higher fat hand. And relative comparison with cheese, yogurt does not contain sodium. So these can be some of the potential mechanism, but we know that there's not much clear evidence in terms of mechanism on why yogurt shows the most strong beneficial association with type two diabetes. What is interesting is that like in relationship with body weight, there is a very large studies, very similar to the one I did on change and intake in type two diabetes, but change and intake and change and weight can commit a change in weight. It was published by Arius Mazzafarian in 2016, I think, also using the Harvard Quartz and increasing yogurt was the food most strongly associated with reduction in weight. So either on weight, when looked at in parallels that they don't type two diabetes, they make a lot of sense because type two diabetes is a disease that developed over time with one of the key risk factor being abdominal obesity, visceral obesity. So if one food can prevent weight gain, it's very likely to prevent type two diabetes and thereafter in the next five, 10 years, probably guardian risk in our business. With some of that epidemiological work, do we have anything that shows us anything about the comparison? In other words, how much we're when we're changing the intake of yogurt up or down in the diet that obviously is being replaced by more or less in the other situation. Do we know how much the what we're comparing it to makes a difference in risk, if that makes any sense? Because presumably that would have some influence on our likely change in risk or how is that accounted for in some of these particular studies we've talked about? In the analysis we did, it was from after serving a day more over 40 perils that was associated with the statistically significant lower risk of type two diabetes. The challenge with yogurt is that the consumption in cohorts and overall the population is quite low. It's less than a serving per day average. So it's quite challenging to see, to see whether at one surveying more or less to surveying. There was an effect because they are too little individual in these range of consumption. So we had to use after surveying per day increment for the data to make sense in terms of interpretation, like to have some kind of a attrition. One of the other outcomes that love us to get to is related to cardiovascular disease, but probably more specifically, there's been work looking at atherosclerosis. And obviously for numerous reasons, we have data outside of dairy foods that implicates high levels of saturated fat driving increases in LDL cholesterol. However, one of the really interesting things that happens when we start looking at dairy is we see that when you have different dairy foods, even of the same amount of saturated fat, we might see differential effects depending on what is that source food. Could you maybe walk through some of that for people who may not have came across this type of idea before? Yeah, these question about like dairy saturated fat, is it the same as like red meat saturated fat or as like any saturated fat? Origin, I think, was from the epidemiological work, which shows that higher intake of cheese is not associated with higher risk of cardiovascular disease. In most meta-analyses and most recent is it's either that there is no evidence of an association between cheese intake and cardiovascular disease risk, or some also report the lower risk of cardiovascular disease. So that doesn't really make sense in a way if cheese is a high fat. High fat food, which also contains some sodium, and it has been in we don't see the association with a higher risk of cardiovascular disease. So then to your question about like, is there anything dairy that may influence this? Well, there have been some clinical trials to try to test the potential matrix effect. So one large trial on this was conducted here at Reston Amal, with Anuana Masha, the senior investigator. And they tested in adults, cardiometabolic profile, I think, the impact of consuming a certain amount of saturated fat from cheese in the diet, with the same amount of saturated fat from butter in the diet. So butter is basically dairy fat, mostly fat, but without like the protein and the micronutrient matrix of cheese. And so it was a very robust design crossover individual receive all their foods, three meals a day, one snack for five or six weeks for each intervention, if I remember well. And overall, what they found is that consuming cheese in the diet or butter increase LDL, but when it's from cheese, the increase is lower than when it's from butter. So again, speaking to the potential matrix effect. So in terms of potential mechanism that could explain this, there is the part where the potential role of council and like binding with the fat and then preventing it being absorbed and then transformed into LDL. So that's, I would say that's the key. That's the main mechanistic eye because it's supporting this. It has been tested, there's at least one study that tested like as the call expression, but the effect is very, there is some three call expression, but quite limited, which is also a bit counterintuitive considering that this is like the main potential mechanism. But nevertheless, we do have this research and has been replicated in other places showing that with that comparison of butter versus cheese, we see these differential effects on LDL cholesterol, even when matching for the same amount of saturated fat. So we see differences there. And so this speaks to, there's something about that food matrix within cheese that is having this beneficial effect of none, maybe a bit far to say beneficial, but at least the elevation LDL cholesterol isn't as high as butter, we could say more specifically. And some of that may be due to calcium and some of these soaps that you set forms to, to prevent this, the LDL cholesterol going as high. And so this is another reason why speaking to the point you made at the start of all these different sub types of food are important because they have now differential effects, even on these biomarkers that we care about. And then ultimately on risk. The other aspect of cardiovascular disease that's related here that maybe doesn't get as discussed much in relation to some of these foods, because a lot of the time that focuses on the fat content and impacts on atherosclerosis, there's some really interesting work on these different dairy foods and the impact on blood pressure and more specifically looking at maybe risk of hypertension. And at least from the outside, one of the things that seems to maybe add some confusion or that we need to have some nuance here is that there can be slight differences between some of those shorter term trials, maybe an RCT that's looking at blood pressure and outcome versus some of the epidemiology we have looking at a long term risk of hypertension. Can you maybe give us an idea of what do we know from the broader evidence base around the consumption of these different types of dairy products on blood pressure or hypertension risk? And then beyond that, how do we consolidate potential differences we might see between the short term trials and the epidemiology in this area? In terms of the association with hypertension, again, it doesn't mean part of the discussions for 10, 15, 20 years because of the content of dairy, especially milk and calcium, phosphorus, potassium, which are known to have beneficial impact on, potentially beneficial impact on blood pressure. And all of that research on dairy, milk and blood pressure, the most, the first and one of the most striking data on this was from the DASH trial. So the DASH trial was conducted late nineties or early 2000, testing the effect of the DASH diet, which is like high in the fruit and vegetable, low in high fat processed meat and contains some low fat dairy. So that's the typical definition of DASH diet. It's an American LT dietary pattern, which kind of have many feature of what we can see right now in the population guidelines across the world. So in the DASH trial, there was three study arms, a controlled low fat diet, a DASH diet without milk and dairy, and the DASH diet containing milk and dairy. And the blood pressure reduction was the strongest, most impactful in the DASH diet with dairy. So all this kind of suggested potential plus value of including low fat milk, low fat dairy in the diet in terms of blood pressure control. And this study was conducted into an hypertensive individual. In parallel, there are several genealogical studies on dairy and taking risk of hypertension in my group. We published in 2021 an updated systematic list of prospective cohorts. And like for the total dairy exposure in relation with hypertension, we had 23 risk estimates. So that's why substantial number of prospective cohorts. And in this analysis, milk was associated with a lower risk of hypertension, but not cheese and yogurt. That's kind of speaking to the matrix effects. And again, like potassium, potassium, magnesium are the nutrients of interest in this. In 2014, we conducted here a intervention study that was part of my master thesis. And we tested the impact of like reserving a day of dairy, which was the level recommended at that time in Canada's food guide of dairy, mainly on blood pressure in hypertensive individuals, but measured with ambulatory blood pressure monitor lights for 24 hours. So that's the best way to measure blood pressure. We didn't see much of an effect of reserving a day of dairy over four weeks on blood pressure in these individuals. And in the control intervention, the withdraw had to consume like a snack that comprises nuts, vegetable juice and a cookie. So we kind of tried to match for macronutrients. We didn't see an effect. So is it like contradictory to all the epidemiological studies? For this, I'm not sure how I see it for blood pressure. See how hypertension, your blood pressure has to rise slowly, slowly until you reach the threshold that is considered hypertension. We don't necessarily with the diet, we don't necessarily needs to reduce blood pressure, just need to prevent an increase in blood pressure. If dairy nutrients, milk nutrients can prevent some sort of increase in blood pressure that over the long term, that could explain why we see in prospective court lower risk of hypertension in a neutral consuming amount of milk. That's how I try to make sense of like reconcile data from several trials on blood pressure and with enduring blood pressure and the neurological evidence. Great. There's one thing that you mentioned briefly in your answer around the previous dietary guidelines in Canada. And as far, if I am getting this correct because I'm not based there, but I think the dietary guidelines in Canada were one of the first, maybe the first to take dairy from a kind of recommended food group more to an optional kind of status in the most recent iteration. And there's been people in other countries calling for something similar in the sense that, okay, we might have these outcomes where we show lower risk of these certain food groups. But the claim then would be that it's possible with other types of diets that don't include dairy to get a similar risk reduction. And so we should put it in an optional position from your perspective, based on the work you've done in this area, as well as seeing the rationale for this change in dietary guidelines with reference to dairy as a recommended food group or not. What is your take on that transition? And for you, depending on what guidelines we look at, of course, and what country, our recommendations currently in line with best evidence in some guidelines versus others, if that question makes sense. That makes a lot of sense. And it makes a lot of noise when the latest Canada's Food Guide was published because we went from four food groups to three food groups. So before the latest revision was Canada's Food Guide, there was four recommended food groups with specific targets for index per day. There was the cereal, there was the meat and substitute, food and vegetable, and milk and dairy. Like target of, I don't know, one, two, three, serving per days, depending on age, life, or milk and dairy alternative food. The latest revision, like Canada's Food Guide, that is currently recommended, El Cananda decided to revise the approach to LT dieting. And they went to an approach that includes three food groups. The first is fruit and vegetable, which was already there. The old grains grew, and now they are part of the protein food group. So in that sense, I think that makes sense. So they are still recommended. They are optional in the way that I think El Cananda labeled it, that has to some protein foods, part of, like, all the protein foods and including plant protein foods. But there are still milk and dairy are still recommended. That's a very important nuance. I think that, yes, when we look at the picture of the two guidelines side to side, it looks like dairy was removed, but they are not. They are still there. Like now Canada's Food Guide is illustrated as a LT plate with half being fruits and vegetable, one quarter being whole grains and one quarter being protein foods. And in all the protein foods illustrated, you can see some chilies, some yogurt and the milk is part of the LT drinks recommended after water. That's how it's framed. So for me, it makes sense because it is aligned with the focus on plant foods. The need for that kind of transition in the diet to incorporate more fresh, minimally processed food and vegetable, all grains in the diet in replacement of protein foods, which are a little bit more consue. And also all the other process foods that are in the diet. That way that makes sense from the eye. It was on that sense of, well, clarifying, first of all, for the audience that this change in those guidelines does maybe place it as something that's optional, which might be useful for people who, for whatever reason, don't want to consume dairy. I think the previous worry was that we have guidelines and still do in other countries that put it almost as something you should 100% have as part of your diet, and some people don't wish to do that. Whereas with Canada, there's more flexibility now to choose other protein sources. But as you note, it's still within there, within the foods that one could consume as part of a healthy diet. It's not relegated to things to limit or avoid necessarily. And it's also probably useful to think of it as a protein food for the person, the average population, because if we were going to be consuming dairy products, you would probably want to push it towards the foods that are a good source of protein, like the yogurts and maybe cheeses, rather than butter as your whole dairy source, where you're getting, you're probably skewing it more to things like would drive those changes in LDL, as we mentioned. But looking at the things that we do have really positive evidence for. One of the other things that sometimes causes a lot of discussion, but as opposed to understandable, is that with dietary guidelines in some way, they do have to be relatively simplistic for and for a large number of people. And so it's hard to get every single piece of nuance. And with it, when it comes to some of what we've discussed today, there is a lot of nuance, right? When we're even when we're comparing to recommend low fat or high fat dairy products, as you noted, that a lot of the time that depends on, well, which product are we talking about and which outcome? And we might not see that there's a difference there, but we're still going to at least typically we persist with at a public health level of low fat dairy tending to be promoted in place of high fat dairy. And so again, yes, is there some nuance there where you could add to it? Yes. But again, can we fit all of that into easy to see visuals of dietary guidelines? And maybe that's a different question. Yeah, the dairy fat discussion is a complex one. So dairy fats, saturated fat and saturated fat compared to unsaturated fat do some unfavorable carbon metabolic effects. Should they unsaturated fat versus saturated fat? That's like in any trial that will we do cell DL improve triglycerides of this. But then you look at like epidemiological data, as I mentioned earlier, like the individual consume higher intake, higher level of cheese are not necessarily at higher risk of carjovascular disease that does not fit with the unsaturated fat versus saturated fat concept in back on LDO. That's there are also a lot of studies that use dairy fat biomarkers and that they can noic acid and that they can noic acid C15 C17. These are a chain fatty acid that are known to be biomarkers dairy fat intake and in these large consortium of core studies. Full longer data on C15 C17 and risk of, for instance, type two diabetes. The risk is lower. The more you add these biomarkers in the blood, the less the risk of type two diabetes. Type two diabetes risk is lower. So it could suggest so my beneficial association between higher consumption of dairy fat and lower risk of carjovascular disease type two diabetes. So this is quite a conflicting, these are conflicting data when put in parallel with like the dietary guidelines. How I see it is that with the dietary guidelines, as it has to be simple. As you said, there are some balance of risk and benefits to you made the choice of the wording and in the choice of the recommendation. I think that the main issue and the main challenge in testing the effect of low fat versus high fat in either clinical studies or epidemiological studies is to control for what the fat replace or is replaced by. And if an individual take is butter bound in the fridge, put it in the trash bin, replace by a bottle of vegetable oil, any. This is a clear substitution of saturated replacement of saturated fat by unsaturated fat is easy to do, just replace one thing by another in the diet. Person that replace a full shot milk glass by a skim milk glass, reduce in the diet. The intake of saturated fat, saturated fat from milk. So that's sure, but how we quantify and measure the place of fat. Other micronutrients in the diet, it's by relative contribution to total energy in day. It's like to replace 5% fat by 5% unsaturated fat. Placing butter with oil will be, will show some benefit. But when you just replace milk with all milk with skim milk. Sat fat goes down, but unsaturated fat does not necessarily go up. And I think that this part creates a lot of confusion in the epidemiological studies that that is hard to measure, because if this reduction in saturated fat is compensated by refined carbs, not sure there is much of a plus value here. If it's placed by more unsaturated fat, but that practically will imply two change in the diet, replace old milk with skim milk, and then find a way to incorporate more vegetable oil, unsaturated fat in the diet. So that's a more complicated, practically move to do. And I think that plays a lot in the, in the epidemiological studies. And how we cannot find, we don't see that consuming low fat dairy is necessarily better than high fat dairy. And then also in epidemiological studies, there are also some challenges in classifying these foods. So what is low fat? What is high fat? That makes sense to include in the low fat dairy, skim milk, 1% milk, 2% milk, but not whole milk, which is just 1% higher than 2% milk. And then to put in this group, low fat cheese at 80%, 18% sorry, fat. That's the larger range. I think the most, we need more study on reduced fat cheese versus regular cheese, specifically 18% cheese versus 30% plus person fat cheese. Low fat skim milk versus old milk. This will be very challenging, this one, because the consumption of old milk, I think in all Western countries is going down. So we will need like many, many, many, many courts to do this. And after to compare low fat, low fat yogurt to like whole fat yogurt. With these kind of approach, I think we'll have a much clearer sense of the influence of dairy fat on health. But I think for now, for me, I don't think that's much of a big deal about like, should the dietary guidelines, that the, that the dietary guidelines, I can diet US or Europe still continue to recommend low fat, reduce fat theory, I think that makes sense. Because otherwise, it would have to explain why is saturated fat from dairy is different and then good luck. Right. Yeah. As you already, sure. In a simple way. Well, I mean, ultimately. The first hurdle we have to get over is that most people that, as in the vast majority of the population don't eat anywhere close to the guidelines already. So we're already worrying about a small little change. And as it could introduce this potential confusion, if at one point we're saying limit saturated fat, but then we have this other recommendation. Maybe that's a concern for people. But I think the real crucial thing that you've just explained that I really want to highlight for people listening is one of the core concepts of all of nutrition science. When we're looking at what is the effect of a certain type of food on a health outcome, and that question always has to be a bit longer as in, what is the impact of this food compared to a different food? If we don't know what we're comparing it to, it's a, that question makes no sense. If we're saying, what is the impact on cheese on cardiovascular disease? Well, that doesn't make any sense until we say, well, what are we comparing it to? And depending on what that comparison is, we will see a difference, but also beyond that, we have to make sure it's a useful comparison for the real world sometimes. As in, there's no point in comparing it to something that would never be what someone would use in place of cheese, for example, would never appear in their diet that might be useful for ongoing research, looking at nutrients, but ultimately for changes in the diet, we need to look at useful comparisons. And so that's always, I'd say for people listening to really bear in mind the point that has just been made that when you are looking at research and trying to get to these questions, can you find out what is it being compared to? What is that comparison that is going on when we're looking at a higher or lower amount of a certain food in the diet? Because when we change the amount of that food or that nutrient or whatever it is, we're going to have to change other things. And we need to make sure we know what that comparison is. So I think that was a really crucial point that you made and would serve people even beyond this particular topic, looking at all of nutrition. And I think that this speaks to the protein food group in Canada's food chain. For me, that's seeing that way. That makes a lot of sense to put dairy in this protein food group, because then we can after test and we have done it in some of my dairy paper and rendit paper and eggs paper on diabetes and CVD in the overt course. We did some kind of substitution analysis like this, like what happens when you replace an egg day by a serving of yogurt. Day or by a serving of meat or bacon processed meat. Then these are important because like in a standard American breakfast, like these are the protein foods that we will look at and maybe swap. And what we saw is that like in most of these substitution studies in relation with type two diabetes, I'm replacing processed meat with basically any other protein food that was associated with lower risk of type two diabetes. For dairy, there were always kind of in the middle. So there was some food that were better, some food that were worse. But it's kind of a, how I see it is like kind of a gradient in life. There is a gradient in the association between different types of protein foods and the risk of type two diabetes. And when you swap a lower risk one by a higher risk one, there is a gain here. So like with dairy in most of these studies by like having some associated with lower risk when it's replaced or higher risk. So having them in the middle is like it's not, it's fine to have some in the diet. You can't live without, but there is some gain of some time of including during the diet, that's how I, and that's a bit how it is formulated in Canada's food guide, protein foods group recommendations. So I think it's fine. So before I get to my very final question, for anyone that's listening, who is interested in maybe learning more about your work or your lab or the group and the research that you've got going on, is there any place on the internet that you would send their attention towards if they were looking to learn a bit more about the work that you're doing? People can find me on LinkedIn on bomet for my papers. There's only one one shot see on bomet and it's me. So it's easy to find my papers. So LinkedIn is the place. Otherwise, by email, you can reach out and be happy to discuss. Perfect. And in the description box for this episode, I will put details of all of that as well as links to any of the research that we discussed today, which I go and recommend people go and read the full text of. So that brings us to the final question that I always end the podcast on, which can be completely outside of anything that we've discussed so far. Quite a broad question. So apologies for putting you on the spot with this. But it's simply if you could advise people to do one thing each day that might have a positive impact on their health, what might that one thing be? It's a good question. I'll go with a very simple dietary advice. Wouldn't be to replace any refined grain food by old grain. I know for past and spaghetti, this doesn't taste exactly the same, but it's very simple. I don't need more cooking skill. Don't cost about the same life, but it will increase your fiber intake. And all over the long term, it will be very beneficial. Remove one. It's hard to find two things that have as much consistent and strong evidence as those two recommendations you've given. So with that, thank you so much for giving up your time to come and talk to me. But even more so, thank you for your great contributions to the field of nutrition science. So thank you and thank you for coming to talk to me about it. Thank you very much. It was a pleasure. Thanks so much for listening into today's episode. Before you go, I just wanted to remind you about Sigma Nutrition Premium, our subscription for those of you podcast listeners who want to significantly deepen your understanding of nutrition science and become truly confident in your knowledge. So what's the idea of this subscription? Essentially, it was created with the goal of allowing you to more deeply understand the material you're hearing on the podcast episodes themselves to be able to retain more of that after you finished listening or reading through the notes and then be able to easily and efficiently revise over that so that in the future, you can be able to remember that information, to be able to reuse it, to be able to create your own content or ideas using things that you have learned. And how do we go about this? Well, there's a few different ways, but at the core of the subscription is our detailed study notes that you get to each episode where you get a beautiful PDF that is full of all useful descriptions, background context, diagrams, charts, etc. To allow you to more deeply understand some of the concepts that were mentioned throughout that particular episode, as well as them linking them back to previous episodes. You also get these segments at the end of each episode called our Key Ideas segment, where I recap certain key ideas. You get episode transcripts. You get then a number of premium only episodes. So you have your own premium podcast feed that appears on whatever app you already use, and you get these extra premium only episodes. Some of them might be Ask Me Anything sessions where we answer your questions that you submitted directly, or they could be a variety of other episodes that you may have seen previews to in the public feed. So for full details on this, then check out the link in the description box wherever you're currently listening right now, or just go to sigmanutrition.com and you can see all the details there. And of course, your support is what keeps sigmanutrition going. We don't run ads, we don't sell supplements, anything like that. So your support is what allows me to continue to do this. So thank you for that. I hope you do come back for the next episode, regardless. And until then, have a great week, stay safe and take care.