The link between the consumption of dairy products with 10-year Framingham risk Score among women

Abstract

Background

Given that in Iran women are more at risk of cardiovascular diseases (CVDs) than men, the aim of the present study was to investigate the consumption of dairy products in relation to Framingham risk Score (FRS) and cardiovascular risk factors in women.

Methods

371 women aged 18 to 50 years were recruited in this cross-sectional study. A validated and reliable food frequency questionnaire was used to measure diet. A 10-year odds of developing CVD between participants was predicted using FRS.

Results

Higher intake of total dairy, low-fat and high-fat dairy products was associated with higher FRS, but receiving each dairy, in particular, had nothing to do with FRS. Doogh consumption was directly associated with fasting blood sugar (FBS) (Odds ratio (OR): 14.11, 95% confidence interval (CI): 1.97, 101.03; P = 0.999). Also intake of high-fat dairy was directly correlated with serum levels of triglyceride (TAG) (OR: 4.47, 95% CI: 1.75, 11.43; P = 0.999). However, no correlation was observed between dairy products and other CVD risk factors.

Conclusions

Overall, consumption of doogh and high-fat dairy products was correlated with greater serum levels of FBS and TAG, respectively. Intake of total dairy, low-fat and high-fat dairy products was also associated with higher FRS. Future studies are needed to elucidate the link between dairy consumption and risk factors of CVD to characterize gender differences.

Background

Non-communicable diseases, including cardiovascular diseases (CVDs), are one of the major causes of death and morbidity in recent years. About16 million deaths annually are attributed to CVDs⁽¹⁾ It is predicted that in Iran the prevalence of CVDs will be doubled in 2050 compared to 2005⁽²⁾. A part of this considerable prevalence can be explained by the rapid transition of nutrition and adverse changes in dietary habits⁽³⁾. Modifying CVD-related risk factors could be considered as a priority for reducing the mortality rate in each population. Several modifiable risk factors, including hyperglycemia, hyperlipidemia, sedentary lifestyle, unhealthy diets, smoking, and obesity, have been suggested to increase CVD risks⁽²⁾. Previous studies showed that high triglyceride levels (TG) and total cholesterol (TC) were observed in 40.2% of the Iranian population aged 30 and over. In addition, the prevalence of hypertension and obesity in this population was 36.1% and 22.7%, respectively⁽⁴⁾. Based on evidence, women are more likely than men to develop risk factors of CVD such as diabetes mellitus, obesity, hypertriglyceridemia, and hypercholesterolemia⁽⁴˒⁵⁾. Therefore, women are more at risk for CVDs in Iran⁽⁶⁾. Improving risk factors, including eating habits, can decrease clinical events in CVD people, as well as in people at high risk for cardiovascular disease because of ≥ 1 risk factors, and a varied and balanced diet under a healthy lifestyle is considered to be the most important strategy for CVD prevention⁽⁷⁾.

Most dietary guidelines recommend milk and dairy products consumption as a main part of a well-balanced, healthy diet⁽⁸˒⁹⁾. Dairy products are a various food group, a number are non-fermented (such as milk), and others (such as cheese and yogurt) are fermented⁽¹⁰⁾, which different types can result in different outcomes of health, and this might be due to fat content and other components of dairy group⁽¹¹⁾. There are beneficial products in dairy products such as saturated fats with medium-chain and odd-chain, spherical phospholipids, special amino acids, natural trans fats, branched-chain and unsaturated fats, vitamin K1 and K2, and calcium. Vitamin K2, found naturally in fermented dairy products, has been proposed to reduce Coronary Heart Diseases (CHD) and aortic calcification⁽¹²٬¹³⁾. Dairy can contain probiotics, which many of them may have health consequences.

Dairy products are also a major saturated fat food source. Dairy fat is often portrayed as a negative part of dairy products, largely due to its high energy density and rich source of cholesterol⁽⁹⁾. Saturated fat intake enhances low-density lipoprotein cholesterol (LDL-C)⁽¹⁴⁾ and the LDL-C to high-density lipoprotein cholesterol (HDL-C) ratio⁽⁹⁾. It may lead to chronic inflammation, which based on this and also based on the data obtained from ecological studies, receiving dairy products has long been considered as a risk factor in cardiovascular diseases⁽¹⁵٬¹⁶⁾. In a cohort study, dairy fat consumption in women was associated with a slight increase in Ischemic Heart Disease (IHD) mortality⁽¹⁷⁾. On the other hand, a meta-analysis of cohort studies on the risk of cardiovascular disease and milk did not provide any convincing evidence that milk was harmful, offering that milk drinking might be correlated with a small but valuable reduction in stroke risk and heart disease⁽¹⁸⁾. Moreover, in a cohort study, consuming more total dairy (> 2 servings per day) was correlated with a lower cardiovascular mortality risk compared to not consuming it, and similar relationships were observed for low-fat and high-fat dairy products⁽¹⁹⁾.

The Framingham Risk Score (FRS) is one of accurate and reliable risk prediction tools in the long term. It was used in Framingham Heart Study data to determine a person's 10-year chance of developing CVDs⁽²⁰⁾. FRS considers six coronary artery risk factors including sex, age, smoking habits, TC, HDL-C, and systolic blood pressure⁽²¹⁾. Notably, the validity and reliability of this tool for predicting CVDs risk in Iranian populations have been previously reported⁽⁷ ̵ ¹⁰⁾.

Numerous studies have examined the correlation between dairy consumption and the risk of CVDs. Although the FRS were used in only three studies⁽¹²٬¹³٬¹⁵⁾. Of these three studies, the outcome of two studies is cardiovascular diseases, which one was conducted in Korea and found the link between milk consumption and Framingham risk score⁽¹³⁾ and another has found a general link between lifestyle and CHD⁽¹⁵⁾. Due to the contradictory results of previous studies, the geographical differences in dairy consumption⁽¹⁴⁾, and the lack of relevant reports in Iran, the present study purpose was to clarify the association between various types of dairy products (milk, yogurt, and cheese) with a 10-year risk of Framingham score.

Methods

Results

General characteristics of 371 women across dairy tertiles are reported in Tables 1 and 2. Milk and low-fat dairy consumption were associated with age (P = 0.003 and P = 0.033, respectively). Between yogurt consumption with BMI (P = 0.017) and SES )P = 0.0001), cheese consumption with age (P = 0.034 (and weight (P = 0.003) and waist circumference (P = 0.0001) and BMI (P = 0.003) and SES (P = 0.015), and doogh consumption with age (P = 0.0001) and BMI (P = 0.016) and waist circumference (P = 0.001) and SES (P = 0.048) were observed. Consumption of high-fat dairy products was also significantly associated with age (P = 0.0001), waist circumference (P = 0.006), SES (P = 0.0001) and multivitamin supplementation (P = 0.021). However, there was no association between total dairy consumption and any of the demographic indicators (P ≥ 0.05).

Dietary intake across dairy consumption tertiles is presented in Tables 3 and 4. Participants in the high category of milk consumption had higher energy intake, macronutrients, saturated fatty acids (SFA), and several nutrients (vitamin B12, vitamin A, vitamin D,, magnesium, calcium, phosphorus, potassium,, zinc and iron), and people in the upper category of yogurt had higher energy intake, carbohydrates, fats, SFA, vitamin B12, vitamin B6, vitamin D, vitamin A, phosphorus, potassium, calcium, zinc and iron. Higher intake of total energy, carbohydrates, fats, dietary fiber, SFA, vitamin B12, vitamin B6, vitamin D, vitamin E, calcium and potassium were observed in the higher cheese consumption tertile, and higher intakes of energy, protein, dietary fiber, vitamin B6, vitamin A, vitamin K, Vitamin D, potassium, calcium, and magnesium were seen in higher tertile of doogh consumption. Higher tertiles of low-fat dairy intake was correlated with higher energy intake, protein, carbohydrates, dietary fiber, vitamin B12, vitamin B6, folate, vitamin D, vitamin K, calcium, potassium, magnesium, zinc and iron, and higher tertiles of high-fat dairy consumption was correlated with higher energy, fat, dietary fiber, SFA, vitamin D, vitamin E, vitamin B6, vitamin B12, calcium and iron. People in the higher group of total dairy consumption also had higher intakes of energy, protein, dietary fiber, SFA, vitamin B12, vitamin B6, folate, vitamin A, vitamin D, vitamin E, vitamin K, potassium, calcium, zinc, magnesium and iron.

The means and standard deviation (SD) of FRS and other risk factors for cardiovascular disease across dairy consumption tertiles are depicted in Tables 5 and 6. Participants in the highest milk consumption category compared to those in the lowest category had the lowest HDL-C (47.83 ± 0.68 vs. 48.01 ± 0.67 P < 0.001), and the highest TAG (111.8 ± 4.79 vs. 103.1 ± 4.69; p = 0.6), LDL-C (83.34 ± 1.46 vs. 77.07 ± 1.43; <0.001 p), TC / HDL-C (3.92 ± 0.08 vs. 3.82 ± 0.08; P = 0.002), and FBS (90.94 ± 0.74 vs. 87.07 ± 0.72; p = 0.001). HDL-C also decreased significantly across tertiles of yogurt, cheese, doogh, total dairy, high-fat dairy, and low-fat dairy intake (47.83 ± 0.68 vs. 48.01 ± 0.67; p < 0.001), but LDL (83.34 ± 1.46 vs. 77.07 ± 1.43; p < 0.001), TC / HDL-C (3.92 ± 0.08 vs. 3.82 ± 0.08; p = 0.002) and FBS (90.94 ± 0.74 vs. 87.07 ± 0.72; 001 / 0 = p) increased.

The odds ratios (OR) and 95% confidence intervals (CI) of cardiovascular risk factors, in the crude and modified models across total dairy consumption and each of its types, are shown in Tables 7–9. Subjects with a greater intake of high-fat dairy had higher serum TG levels (OR: 4.47, 95% CI: 1.75, 11.43; P = 0.999), but no association was observed between high consumption of high fat dairy and LDL-C, TC and HDL (OR: 0.19, 95% CI: 0.01, 3.2; P = 0.999, OR: 0.74, 95% CI: 0.11, 4.84; P = 0.999 and OR: 1.39, 95% CI: 0.19, 10.08; P = 0.366, respectively). Participants with the highest tertile of milk, yogurt, cheese, doogh, low-fat dairy, and total dairy consumption compared to those in the lowest tertile, did not show a significant link with lower serum levels of TG (OR: 0.05, 95% CI : 0.003, 1.09; P = 0.999), LDL-C (OR: 0.19, 95% CI: 0.01, 3.2; P = 0.999), TC (OR: 0.74, 95% CI: 0.11, 4.84; P = 0.999), and higher serum levels of HDL-C (OR: 1.39, 95% CI: 0.19, 10.08; P = 0.366).

Discussion

The present cross-sectional study indicated that women who consumed high amounts of dairy products had higher Framingham scores. Regarding the dairy products consumption and CVD risk factors also the link between the consumption of doogh with FBS and high-fat dairy products with TAG was observed. To our knowledge, no earlier studies have applied the FRS to assess the association between total dairy consumption and each type with a 10-year risk of cardiovascular disease. Only one study examined the association of milk consumption with FRS. The current study is the first to offer information on the relationship between total dairy consumption, and each of its types with Framingham score, and risk factors for CVD in women. In this study, we also considered the relationship between the consumption of doogh, which is one of the types of dairy products that are traditionally used in our country.

The FRS is a standard indicator, predicting a 10-year odd of developing CVD in persons who appear to be healthy⁽²⁴⁾. Previous studies have shown that FRS is an appropriate indicator for ranking subjects, and could be applied to examine the relationship between non-clinical factors and health⁽²⁷ ̵ ³¹⁾. FRS considers seven cardiovascular risk factors for its prediction, including age, sex, smoking, blood pressure,, HDL-C, TC, and history of diabetes⁽³²⁾. In the present study, the intake of total dairy and each of its types was directly related to future CVD events. The only study that used the FRS index did not agree with our result. Joo et al. showed that consuming more milk was associated with less FRS in Korean population. They examined only frequency intake of milk consumption with no attention to the amount of intake⁽¹³⁾.

Although so far only one study, as mentioned, has been conducted on FRS and milk consumption, several studies have examined the association of Framingham index components with dairy consumption. But the number of cohort studies that have seen relevance over a long period of time is not large, almost all of them have seen the opposite relationship or have not seen a connection. In the cohort study by Wang et al., it was showed that higher consumption (≥ 3 servings per day or week vs. <1 serving) of yogurt, total dairy, fermented milk products, and skimmed / low-fat milk, was correlated with a 0.2–0.6 mm Hg lower increase in SBP / year, and the extent of this link also decreased over time (i.e. with increasing age) in European population⁽¹²⁾. Heraclides and his colleagues also did not observe any favorable variation in hypertension (HTN) risk in the 1750 participants consuming dairy products, including total dairy, low-fat dairy, high-fat dairy, and fermented dairy after 10 years of follow-up⁽³³⁾. As mentioned, the Heraclides study categorized dairy products only in terms of fat and fermentation or not, did not examine all types of dairy products. Also it used a 5-day food recall to assess dairy intake, which was different from the tools we used. A longitudinal study by Drehmer et al. also found that dairy consumption, particularly fermented dairy, was inversely related to blood glucose and insulinemia measurements in Brazilian adults without diagnosed diabetes⁽³⁴⁾.

In this study, women with higher levels of doogh consumption showed higher serum FBS levels. There is no article on blood sugar and doogh consumption, and also there is no convincing explanation for this connection.

The present cross-sectional study showed that women with higher levels of high-fat dairy consumption had higher serum TAG levels. Similarly, in the study of Machlik et al., the consumption of low-fat cheese had a more favorable relationship with blood lipids than regular-fat cheese. However, this association was only observed with cheese and there was no significant relationship between low-fat yogurt and blood lipid concentration⁽³⁵⁾. Other studies disagreed with our finding. Chiu et al. study showed that a HF-DASH (high-fat dietary approaches to stop hypertension) diet reduced triglycerides compared to a regular dash diet, which in HF-DASH diet low-fat and nonfat dairy products were replaced by full-fat dairy products such as whole milk, cheese, and yogurt⁽³⁶⁾. In the study of Kai et al., there was also no relationship between high-fat dairy consumption and lipid parameters⁽³⁷⁾.

In the present study, we found no significant association between dairy consumption and its types with cardiovascular risk factors including HDL-C, TC, LDL-C, TG / HDL, TC / HDL, and FBS. This finding is consistent with a cross-sectional study performed to evaluate the association between dairy consumption and inflammation and cardiovascular risk factors among 107 elderly people aged 60–78 years. Rashidipour Fard and colleagues observed a higher but insignificant risk of an increase in TC and LDL with higher dairy intake⁽³⁸⁾. In studies with yogurts fermented with different strains of probiotic bacteria, some, but not all, demonstrated favorable influences on blood lipoproteins and lipids⁽³⁹⁾. In the study by Sadeghi et al., an inverse link was found between cheese consumption frequency and cardiovascular risk factors (including HDL-C, LDL-C, TG and FBS). However, this study used qualitative FFQ, which may lead to incorrect classification and underestimation, and provide only a rough estimate of cheese consumption. Moreover, in the study of Sadeghi et al., adjustment was not performed for receiving dietary supplements, and no attention was paid to the fat content of cheese⁽⁴⁰⁾.

In one clinical study, dairy consumption reduced FBS in the normal weight subgroup.In our study, with increasing tertile of dairy consumption, people's BMI increased, which may be a reason not to see a connection. However only men were included in mentioned clinical study⁽⁴¹⁾. In contrast to our study, Huth et al. showed that diets containing higher SF from whole milk increase LDL-C, which, occurred when substituted for unsaturated fatty acids or carbohydrates⁽³⁹⁾. In contrast, an American study found that consuming more dairy foods (whether low-fat or high-fat) was associated with better cardiovascular health. This study used the CHS (Cardiovascular Health Score) index to assess cardiovascular health, the components of which were different from the components we used for cardiovascular health⁽⁴²⁾.

As far as we know, there are limited research on the correlation between dairy consumption among women who are at greater risk for CVD. The use of semi-quantitative FFQ alongside main confounding variables is the prime strength of our current outcomes. We also examined the relationship between consumption of all kinds of dairy and low-fat and high-fat dairy products with CVD risk factors, and Framingham risk score, separately. However, this study has many limitations, which should be considered in subsequent studies. The cross-sectional design of the study did not let us make causal inferences. Thus, prospective assessments are required to specify these causations over longer courses. Dietary intake evaluation was not conducted with the weighted dietary records as a gold status way alongside FFQ. However, the reliability and validity of the FFQ have already been reported. Energy consumption was computed based on FFQ, which can lead to biased results. Our sample population consisted only of women, so we were unable to generalize our findings to both sexes. Eventually, however many major confounders were adjusted, the residual confounders are still possible.

Conclusions

In the present cross-sectional study, women with higher consumption of doogh and high-fat dairy products have greater serum levels of FBS and TAG respectively compared with those with lower consumption. However there was no association between dairy products other than doogh, low-fat and high-fat dairy products with other CVD risk factors. About FRS, intake of total dairy, low-fat and high-fat dairy products was associated with higher FRS. However no correlation was found between other dairy products alone with FRS. Future studies are needed to elucidate the link between dairy consumption and risk factors of CVD to characterize gender differences.

Abbreviations

CVD: cardiovascular disease, FRS: Framingham risk score, FBS: fasting blood sugar, OR: odds ratio, CI: confidence interval, TAG: triglyceride, CHD: coronary heart disease, LDL-C: low-density lipoprotein cholesterol, HDL-C: high-density lipoprotein cholesterol, IHD: ischemic heart disease, TUMS: Tehran university of medical sciences, FFQ: food frequency questionnaire, TC: total cholesterol, SBP: systolic blood pressure, BMI: body mass index, WHR: waist to hip ratio, SES: socio-economic status, MET: metabolic equivalent task, PA: physical activity, ANOVA: analysis of variance, SFA: saturated fatty acids, SD: standard deviation, HTN: hypertension, DASH: dietary approaches to stop hypertension, HF: high-fat, CHS: cardiovascular health score.

Declarations

Ethics approval and consent to participate

Informed consent was obtained from all individual participants included in the study.

Consent for publication

Patients signed informed consent regarding publishing their data.

Availability of data and materials

The datasets used and analysed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

This work was supported by the Tehran University of Medical Sciences (grant number 99-3-212-50759)

Authors’ contributions

ZS wrote the article. NN performed data analysis and edited the article. LA corresponded and supplied the data of the article. 

Acknowledgments

We thank all those involved and participants for taking part in the present study. 

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Tables

Table 1 is available in the Supplemental Files section.