Send to

Choose Destination
Lancet. 2018 Nov 24;392(10161):2288-2297. doi: 10.1016/S0140-6736(18)31812-9. Epub 2018 Sep 11.

Association of dairy intake with cardiovascular disease and mortality in 21 countries from five continents (PURE): a prospective cohort study.

Author information

Population Health Research Institute, McMaster University, Hamilton, ON, Canada. Electronic address:
Population Health Research Institute, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
Population Health Research Institute, McMaster University, Hamilton, ON, Canada.
Madras Diabetes Research Foundation, Chennai, India.
Department of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan.
Department of Medicine, Eternal Heart Care Centre and Research Institute, Jaipur, India.
Faculty of Health Sciences, Simon Fraser University, BC, Canada.
Centre of Excellence for Nutrition, North-West University, Potchefstroom Campus, South Africa.
Dante Pazzanese Institute of Cardiology, São Paulo, Brazil.
Research Department, Fundacion Oftalmologica de Santander, Medical School, University of Santander, Floridablanca-Santander, Colombia.
Division of Epidemiology and Population Health, St John's Medical College and Research Institute, Bangalore, India.
Faculty of Health Sciences, Achutha Menon Centre for Health Science Studies Health Action by People, Thiruvananthapuram, Kerala, India.
Post Graduate Institute of Medical Education and Research (PGIMER) School of Public Health, Chandigarh, India.
College of Health Sciences, Physiology Department, University of Zimbabwe, Harare, Zimbabwe.
Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia.
Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran.
Department of Internal Medicine, Istanbul Medeniyet University Faculty of Medicine, Istanbul, Turkey.
Department of Medicine, Universidad de La Frontera, Francisco Salazar, Temuco, Chile.
Department of Dietetics, Wroclaw Medical University, Wroclaw, Poland.
Närhälsan R&D Centre Skaraborg Primary Care Skövde and Department of Public Health and Community Medicine, Primary Health Care, the Sahlgrenska Academy, University of Gothenburg, Sweden.
Department of Medicine, Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia; Department of Medicine, UCSI University, Cheras, Selangor, Malaysia.
School of Public Health, University of the Western Cape, Cape Town, Western Cape Province, South Africa.
Department of Medicine, University of the Philippines, Manila, Philippines.
Dubai Medical University, Hatta Hospital, Dubai Health Authority, Dubai, United Arab Emirates.
Estudios Clinicos Latinoamerica, Rosario, Santa Fe, Argentina.
Institut universitaire de cardiologie et pneumologie de Québec, Université laval, QC, Canada.
Departments of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.
Center for Disease Control and Prevention of Xinjiang Hetian, Xinjiang, China.
Department of Medicine, Queen's University, Kingston, ON, Canada.
Department of Community Health, University Kebangsaan Malaysia Medical Centre, Malaysia.
Friedman School of Nutrition Science and Policy, Tufts University, Medford, MA, USA.
School of Life Sciences, Independent University, Bashundhara, Dhaka, Bangladesh.



Dietary guidelines recommend minimising consumption of whole-fat dairy products, as they are a source of saturated fats and presumed to adversely affect blood lipids and increase cardiovascular disease and mortality. Evidence for this contention is sparse and few data for the effects of dairy consumption on health are available from low-income and middle-income countries. Therefore, we aimed to assess the associations between total dairy and specific types of dairy products with mortality and major cardiovascular disease.


The Prospective Urban Rural Epidemiology (PURE) study is a large multinational cohort study of individuals aged 35-70 years enrolled from 21 countries in five continents. Dietary intakes of dairy products for 136 384 individuals were recorded using country-specific validated food frequency questionnaires. Dairy products comprised milk, yoghurt, and cheese. We further grouped these foods into whole-fat and low-fat dairy. The primary outcome was the composite of mortality or major cardiovascular events (defined as death from cardiovascular causes, non-fatal myocardial infarction, stroke, or heart failure). Hazard ratios (HRs) were calculated using multivariable Cox frailty models with random intercepts to account for clustering of participants by centre.


Between Jan 1, 2003, and July 14, 2018, we recorded 10 567 composite events (deaths [n=6796] or major cardiovascular events [n=5855]) during the 9·1 years of follow-up. Higher intake of total dairy (>2 servings per day compared with no intake) was associated with a lower risk of the composite outcome (HR 0·84, 95% CI 0·75-0·94; ptrend=0·0004), total mortality (0·83, 0·72-0·96; ptrend=0·0052), non-cardiovascular mortality (0·86, 0·72-1·02; ptrend=0·046), cardiovascular mortality (0·77, 0·58-1·01; ptrend=0·029), major cardiovascular disease (0·78, 0·67-0·90; ptrend=0·0001), and stroke (0·66, 0·53-0·82; ptrend=0·0003). No significant association with myocardial infarction was observed (HR 0·89, 95% CI 0·71-1·11; ptrend=0·163). Higher intake (>1 serving vs no intake) of milk (HR 0·90, 95% CI 0·82-0·99; ptrend=0·0529) and yogurt (0·86, 0·75-0·99; ptrend=0·0051) was associated with lower risk of the composite outcome, whereas cheese intake was not significantly associated with the composite outcome (0·88, 0·76-1·02; ptrend=0·1399). Butter intake was low and was not significantly associated with clinical outcomes (HR 1·09, 95% CI 0·90-1·33; ptrend=0·4113).


Dairy consumption was associated with lower risk of mortality and major cardiovascular disease events in a diverse multinational cohort.


Full funding sources are listed at the end of the paper (see Acknowledgments).

Supplemental Content

Full text links

Icon for Elsevier Science
Loading ...
Support Center