NUTRITIONRESEARCHXX(2014)XXX– XXX

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Dairy food intake is positively associated with

cardiovascular health: findings from Observation of
Cardiovascular Risk Factors in Luxembourg study☆

Georgina E. Crichtona, b,⁎, Ala’a Alkerwib

a
Nutritional Physiology Research Centre, University of South Australia, Adelaide, Australia
b
Centre de Recherche Public Santé, Centre d’Etudes en Santé, Strassen, Grand Duchy of Luxembourg

ARTICLE INFO A BSTRACT

Article history: Conflicting findings have been reported about dairy food consumption and risk for
Received 18 December 2013 cardiovascular disease. Furthermore, few studies have examined dairy food intake in
Revised 21 March 2014 relation to cardiovascular health and the incorporation of lifestyle factors such as diet and
Accepted 2 April 2014 physical activity. This study examined whether dairy food consumption was associated
with cardiovascular health, recently defined by the American Heart Association. Data were
Keywords: analyzed from 1352 participants from the Observation of Cardiovascular Risk Factors in
Dairy food Luxembourg survey. A validated food frequency questionnaire was used to measure intakes
Milk of milk, yogurt, cheese, dairy desserts, ice cream, and butter. Seven cardiovascular health
Yogurt metrics were assessed: smoking, body mass index, physical activity, diet, total cholesterol,
Cardiovascular health blood pressure, and fasting plasma glucose. A total cardiovascular health score (CHS) was
Diet determined by summing the total number of health metrics at ideal levels. It was
hypothesized that greater dairy food consumption (both low fat and whole fat) would be
associated with better global cardiovascular health, as indicated by a higher CHS. Total dairy
food intake was positively associated with the CHS. Higher intakes of whole fat milk, yogurt,
and cheese were associated with better cardiovascular health. Even when controlling for
demographic and dietary variables, those who consumed at least 5 servings per week of
these dairy products had a significantly higher CHS than those who consumed these
products less frequently. Higher total whole fat dairy food intake was also associated with
other positive health behaviors, including being a nonsmoker, consuming the suggested
dietary intakes of recommended foods, and having a normal body mass index. Increased
dairy food consumption was associated with better cardiovascular health.
© 2014 Elsevier Inc. All rights reserved.

Abbreviations: AHA, American Heart Association; BMI, body mass index; BP, blood pressure; CHS, cardiovascular health score; CVD,
cardiovascular disease; Non-RFS, non-Recommended Food Score; ORISCAV-LUX, Observation of Cardiovascular Risk Factors in
Luxembourg; RFS, Recommended Food Score.
☆
This work was supported by a National Health and Medical Research Council Sidney Sax Research Fellowship (Canberra, ACT,
Australia). The authors have no conflict of interest to declare.
⁎ Corresponding author. CRP-Santé, Centre d’Etudes en Santé, 1A rue Thomas Edison, L-1445 Strassen, Luxembourg. Tel.: +352 26 970 394;
fax: +352 26 970 719.
E-mail addresses: whige003@mymail.unisa.edu.au, georgina.crichton@crp-sante.lu (G.E. Crichton).

http://dx.doi.org/10.1016/j.nutres.2014.04.002
0271-5317/© 2014 Elsevier Inc. All rights reserved.

Please cite this article as: Crichton GE, Alkerwi A’, Dairy food intake is positively associated with cardiovascular health:
findings from Observation of Cardiovascular Risk Factors in..., Nutr Res (2014), http://dx.doi.org/10.1016/j.nutres.2014.04.002
2 NUT RI TI O NRESEARC HX X(2014)X X X– X X X

between 2007 and 2009 that was designed to gather information

1. Introduction
on the prevalence of cardiovascular risk factors among the
general adult population of Luxembourg. A random sample of
Cardiovascular disease (CVD) causes more than 4 million
1432 individuals, stratified by sex, age (18-69 years), and district
deaths in Europe and is estimated to cost almost €196 billion
of residence completed the recruitment procedure [12,13]. After
per year [1]. The American Heart Association (AHA) recently
the elimination of those subjects with incomplete information
defined a construct of “ideal cardiovascular health” compris-
on components of cardiovascular health or diet, data were
ing 7 health metrics: not smoking, engaging in sufficient
available for 1352 subjects for the current study. Detailed
physical activity, consuming a healthy diet, maintaining a
information about the study design and sampling methods
normal body mass index (BMI), and having optimal levels of
has been published elsewhere [13]. All participants provided
total cholesterol, blood pressure (BP), and fasting blood
informed written consent. The ORISCAV-LUX was approved by
glucose [2].
the National Research Ethics Committee and the National
Diet is an integral part of CVD prevention. However, the
Commission for Private Data Protection.
evidence regarding the intake of dairy products, particularly
with regard to the fat content of dairy and CVD risk is
2.2. Dietary assessment
inconsistent. Some studies have failed to find an increased
risk of CVD [3] or CVD mortality [4] associated with the intake
2.2.1. Dairy food intakes
of dairy products, regardless of fat content. Other studies
Dietary intake was assessed using a semiquantified food
suggest that the consumption of 3 or more servings per day is
frequency questionnaire, which assessed the frequency of
associated with a reduced risk of CVD [5-7]. However, high fat
consumption of 134 items over the previous 3 months [14].
dairy intake has also been associated with an increased risk of
Participants were asked how often they consumed one
CVD mortality [8]. A recent meta-analysis of randomized
standardized portion of each food (eg, one medium cup [125
controlled trials concluded that increasing dairy food intakes
mL] of milk). The 6 response categories ranged from “never or
did not significantly impact cardiometabolic risk factors [9].
rarely” to “2 or more times per day.” Dairy products included
Few epidemiological studies have examined dairy food
in the questionnaire were milk (skim, semi-skim, and whole),
intake (including both low and high fat products) in relation to
cheese (low fat and regular), yogurt (low fat and regular), dairy
a constellation of health factors and behaviors, such as the
desserts, ice cream, and butter. To facilitate comparison
AHA construct of cardiovascular health. Most studies and
between the different dairy products, the responses were
reviews have focused on risk for “disease” and/or cardiovas-
recalculated into servings per day that were based on
cular “mortality” risk [3-8,10]. As the treatment for and
standard serving sizes (250 mL of milk; 125 g of yogurt, ice
survival from acute cardiovascular conditions improves, the
cream, and dairy desserts; 50 g of cheese; and 30 g of butter)
number of patients living with chronic disease will continue to
[15,16]. For research objectives, dairy food intakes were
increase [11]. Simple lifestyle changes that may impact the
classified into 3 groups: (1) total low fat dairy foods (total
individual risk factors for CVD will become increasingly
consumption of low-fat milk, yogurt, and cheese); (2) total
important for cost-benefit prevention strategies.
whole fat dairy foods (total consumption of whole fat milk,
Encompassing 7 health factors and behaviors, the present
yogurt, and cheese); and (3) total dairy foods (total consump-
study aimed to explore the relationship between dairy food
tion of both low and whole fat milk, yogurt, and cheese as well
consumption and cardiovascular health among adults in the
as dairy desserts, ice cream, and butter).
Observation of Cardiovascular Risk Factors in Luxembourg
(ORISCAV-LUX) survey. First, it was hypothesized that greater
2.2.2. Calculation of healthy diet metric
total dairy food consumption would be associated with better
Two food scores were calculated for the diet metric, a Recom-
global cardiovascular health, as indicated by a higher cardiovas-
mended Food Score (RFS) [17] and a non-Recommended Food
cular health score (CHS). Second, it was hypothesized that ideal
Score (non-RFS) [18]. These scores were used to capture a more
levels of individual health metrics, particularly the health
detailed measure of dietary intakes and variety. Based on the
behaviors, would be associated with greater total dairy food
recommendations of the 2010 Dietary Guidelines for Americans,
intakes. To test these hypotheses, the research objectives were as
the RFS comprised 17 food items [19]. Foods included fruit,
follows: (1) to assess the relationship between the CHS (as a
vegetables, legumes, whole grain cereal products, fish and nuts—
continuous variable) across increasing intakes of total low fat,
items similar to those used previously [17,20]. One point was
total whole fat, and all dairy foods; (2) to compare the CHS across
assigned for consumption of any of the recommended foods at
increasing intakes of individual dairy foods; and (3) to explore
least once per week; otherwise, 0 points were given [17]. A total
relationships between the individual health metrics and total
RFS out of 17 was calculated, with a higher score indicating a
dairy food intakes (low fat, whole fat, and all dairy foods).
higher consumption of recommended food items.
The non-RFS [18], the second component of the diet
metric, included 11 items of which reduced consumption is
2. Methods and materials recommended [19], such as processed meats, refined grains,
solid fats and added sugars, and alcohol. Consumption of
2.1. Study population non-recommended foods at least 2 to 4 times per week was
assigned a score of 1; otherwise, 0 points were assigned
The present study used data from the ORISCAV-LUX survey. [20,21]. A total non-RFS out of 11 was calculated, with
This was a nationwide, cross-sectional study conducted a higher value indicating a higher consumption of

Please cite this article as: Crichton GE, Alkerwi A’, Dairy food intake is positively associated with cardiovascular health:
findings from Observation of Cardiovascular Risk Factors in..., Nutr Res (2014), http://dx.doi.org/10.1016/j.nutres.2014.04.002
 NUT RI TI O N RESEARC H X X (2014) X X X– X X X
nonrecommended food items. To identify their distinct
effects on cardiovascular health as exposure factors, neither
score included dairy products.
2.3. Cardiovascular health
2.3.1. Cardiovascular health assessment
Participants underwent physical and anthropometric mea-
surements, blood tests, and completed self-administered
questionnaires to gain information on demographic and
socioeconomic characteristics. Standardized protocols for
data collection were used.
Blood samples were obtained after an overnight fast.
Standard assay methods were used [22] to obtain fasting
plasma glucose (milligrams per deciliter), total cholesterol
(milligrams per deciliter), low-density lipoprotein (milligrams
per deciliter), high-density lipoprotein (milligrams per decili-
ter), and triglycerides (milligrams per deciliter). Body weight
was measured using a digital column scale (Seca 701; Seca,
Hamburg, Germany) and was recorded to the nearest 0.1 kg
with the subject barefoot and wearing light clothing. Standing
body height was recorded to the nearest 0.2 cm with a portable
wall stadiometer (Seca). BMI was calculated as weight in
kilograms divided by height in meters squared. Using Omrom
MX3 plus automated oscillometric Blood Pressure Monitor (O-
HEM-742-E; Omrom, Matsusaka, Japan), BP was measured at
least 3 times, in a seated position, with a minimum 5-minute
interval between each measurement. The average of the last 2
readings was used in the analysis. Self-reported time spent
engaging in physical activity was obtained from the Interna-
tional Physical Activity Questionnaire [23]. Detailed data
regarding cigarette smoking were obtained from the health
questionnaire, and participants were classified as current
smoker, ex-smoker, or non-smoker.
2.3.2. Cardiovascular health score
Poor, intermediate, and ideal health levels for smoking, BMI,
physical activity, total cholesterol, BP, and fasting plasma
glucose were calculated according to the AHA definitions [2].
Ideal health for each metric are as follows: smoking, never or
quit more than 12 months ago; BMI, less than 25 kg/m2;
physical activity, at least 150 minutes per week; total
cholesterol, less than 200 mg/dL; BP, less than 120/80 mm
Hg; and fasting plasma glucose, less than 100 mg/dL [2]. For
the RFS, scores of0 to 7, 8 to 12, and 13 to 17, were defined as
poor, intermediate, and ideal, respectively. For the non-RFS,
scores of 0 to 2, 3 to 4, and 5 to 11, were defined as ideal,
intermediate, and poor, respectively. A total CHS was
determined by summing the total number of metrics
(smoking, BMI, physical activity, total cholesterol, BP,
fasting plasma glucose, RFS, and non-RFS) at ideal levels,
ranging from 0 (no cardiovascular health components at
ideal levels) to 8 (all cardiovascular health components at
ideal levels).
2.4. Selection of covariates
Age, sex, and total energy intake were included as covariates
as they differed significantly between those with intakes of
less than 3 servings of dairy foods per day and those with
Please cite this article as: Crichton GE, Alkerwi A’, Dairy food intake is positively associated with cardiovascular health:
findings from Observation of Cardiovascular Risk Factors in..., Nutr Res (2014), http://dx.doi.org/10.1016/j.nutres.2014.04.002
3
intakes at least 3 servings dairy foods per day. Education was
included as a covariate as its relationship with nutritional
intake has been established [24]. Higher education may be
associated with increased nutritional knowledge and there-
fore better dietary practices. Furthermore, our past research
has shown positive associations between dairy food con-
sumption and education level [25] and cognitive performance
[25-27]. Hence, education was included as a confounder.
2.5. Statistical analyses
2.5.1. Descriptive
According to the type of variable (continuous or categorical),
independent samples t tests and χ2 were used to assess
differences in demographic variables and the individual
cardiovascular health metrics between those that consumed
less than 3 servings dairy foods per day and those that
consumed at least 3 servings per day. This classification was
selected with reference to the current Luxembourg Dietary
Guidelines that recommend an intake of at least 3 portions of
dairy products per day [28].
The intakes of different types of dairy products were also
described. In consideration of the lower daily intakes of
certain types of dairy products, such as dairy desserts and
ice cream, the intakes were further categorized into 3 levels:
low (<1 serving per week), medium (≥1-5 servings per week),
and high (≥5 servings per week). Then, total low fat, total
whole fat, and total dairy food intakes were described
according to the following low, medium, and high categories:
less than one serving per day, at least 1 to 3 servings per day,
and at least 3 servings per day, respectively.
2.5.2. Analytic
General linear modeling with polynomial trend analyses was
used to compare the CHS (as a continuous variable) across
increasing intakes of total low fat, total whole fat, and all dairy
foods, which were plotted in a clustered column chart.
Associations between the CHS and the consumption of
individual dairy foods (milk, yogurt, cheese, dairy desserts,
ice cream, and butter) were then examined. Statistical
adjustment was made for age, education, sex, total energy
intake, and intake of remaining dairy products. For example,
when assessing the relationship between yogurt intake and
CHS, intakes of milk, cheese, dairy desserts, ice cream, and
butter were statistically controlled for. In addition, total low-
fat dairy food intake was alternatively adjusted for whole fat,
and whole fat dairy food intake was adjusted for low fat.
To explore relationships between the individual health
metrics and total dairy food intakes (low fat, whole fat, and
total all dairy foods), general linear modeling with polynomial
trend analyses was used to compare mean (±SE) intakes of
dairy food (continuous variable, in servings per day) according
to the level of cardiovascular health (poor, intermediate, and
ideal) for each metric (adjusted for age, education, sex, and
total energy intake). Again, total low fat dairy food intake was
adjusted for whole fat, and whole fat dairy food intake was
adjusted for low fat. All statistical analyses were performed
with PASW for Windows version 21.0 software (formerly SPSS
Statistics Inc, Chicago, IL, USA). P < .05 was considered
statistically significant.
4 NUT RI TI O NRESEARC HX X(2014)X X X– X X X

Table 1 – Participant characteristics according to total and total dairy foods. A positive relationship with the CHS was
dairy food intake: ORISCAV-LUX observed for total whole fat dairy foods (milk, yogurt, and cheese)
Characteristic a Total dairy intake Pb (P = .03) but not for total low fat dairy foods (milk, yogurt, and
cheese) (P = .22). Total dairy food intake (all dairy foods, regardless
<3 ≥3
of fat content) was positively associated with the CHS (P = .006).
Serves/ Serves/
day day Regardless of demographics, total energy, and other dairy foods
intake, those who consumed at least 3 servings of total dairy
n = 930 n = 422 foods per day had a significantly higher CHS (4.4/8) than those
M SD M SD who consumed less than one serving per day (3.9/8) (P = .004).
Considering individual dairy foods, the CHS increased
Age 43.6 13.0 45.8 13.2 .004
significantly across increasing intakes of total milk (specifi-
Sex <.001
Males, n (%) 483 73.5 174 26.5
cally whole fat milk [P = .002], total yogurt [P = .004], and total
Females, n (%) 447 64.3 248 35.7 cheese [P = .04]), irrespective of age, education, sex, total
Education, tertiary, n (%) 243 68.5 112 31.5 .82 energy intake, and remaining dairy product intakes (Fig. 2).
Total energy intake 2233 826 2829 1026 <.001 There were no associations between intakes of dairy desserts,
Cardiovascular health metrics ice cream, or butter with the CHS.
BMI, kg/m2 26.7 5.1 26.3 4.8 .17
The exclusion of those participants who reported being on
Smoking, current smoker, n (%) 213 74 75 26 .03
a diet for health problems or to lose weight at the time of the
P h y s i c a l a c t i v i t y , m i n / w k 725 899 839 1003 .04
moderate intensity activity survey (14.4%) did not change these findings.
Fasting plasma glucose, mg/dL 93.3 18.1 92.6 16.8 .52
Total cholesterol, mg/dL 201.9 41.7 200.5 38.1 .54 3.3. The association of dairy food intake and individual
Systolic BP, mm Hg 129.7 17.8 129.7 18.0 .96 cardiovascular health metrics
Diastolic BP, mm Hg 82.4 11.5 82.2 10.3 .75
RFS, 0-17 c 10.0 2.9 11.1 2.5 <.001
Associations between mean intakes of dairy foods (total low
Non-RFS, 0-11 d 2.5 1.4 2.7 1.5 .01
CHS, 0-8 3.8 1.5 4.0 1.5 .04
fat, total whole fat, and total all dairy) according to poor,
intermediate, and ideal levels of cardiovascular health for the
Abbreviation: M, mean. individual metrics are shown in Table 3. Those with ideal
a
Data for participants’ characteristics are presented as mean and
levels for BMI (<25 kg/m2) and smoking (never smoked) had
SD, unless otherwise indicated.
significantly higher intakes of total whole fat dairy foods and
b
P values for testing the differences between low (<3 serves/day)
and high (≥3 serves/day) dairy food consumers (t tests for
continuous variables and χ2 for categorical variables).
c
Recommended Food Score scored out of 17, with higher scores
indicating a higher consumption of foods recommended to increase. Table 2 – Dairy product intakes in ORISCAV-LUX survey
d
Non-Recommended Food Score scored out of 11, with higher scores
indicating a higher consumption of foods recommended to reduce.
Dairy products Dairy intakes, % of sample

Low Medium High

3. Results <1 ≥1-5 ≥5

Serve/wk Serves/wk Serves/wk
3.1. Demographic characteristics and dairy intakes of Total milk 40.0 38.1 21.8
ORISCAV-LUX participants Low fat 63.3 26.0 10.6
Whole fat 71.7 19.3 9.1
Table 1 shows that participants who consumed at least 3 Total yogurt 29.9 39.9 30.2
servings of dairy products per day were slightly older, less Low fat 67.1 20.7 12.2
Whole fat 50.9 33.6 15.5
likely to smoke, engaged in more physical activity per week,
Total cheese 11.8 45.3 42.9
and frequently consumed more “recommended” foods (higher
Low fat 61.7 31.9 6.4
RFS) (all P < .05). They had a significantly higher mean CHS Whole fat 18.2 51.6 30.2
(4.0 ± 1.5) compared with those who consumed less than 3 Dairy desserts 85.1 14.2 0.7
servings of dairy products per day (3.8 ± 1.5) (P = .04). Ice cream 91.7 8.2 0.1
As shown in Table 2, nearly one-third of the sample (31.3%) Butter 43.7 25.9 30.4
consumed 3 servings of dairy foods per day. Of those who
Low Medium High
consumed 3 daily servings, a greater proportion consumed
whole fat products (8.1%) than low fat products (3.0%). Among <1 ≥1-3 ≥3
the different types of dairy foods, cheese was the product Serve/day Serves/day Serves/day
most frequently consumed with approximately 43% of the Total low fat dairy a 73.1 23.9 3.0
participants consuming at least 5 servings per week. Total whole fat dairy b 51.5 40.5 8.1
Total dairy c 13.7 55.0 31.3
3.2. The association of dairy food intake and CHS
a
Total low fat dairy = low fat milk, yogurt, and cheese.
b
Fig. 1 illustrates the multivariate adjusted means of CHS across Total whole fat dairy = whole fat milk, yogurt, and cheese.
c
Indicates the sum of a + b + dairy desserts, ice cream, and butter.
increasing intakes (low, medium, and high) of low fat, whole fat,

Please cite this article as: Crichton GE, Alkerwi A’, Dairy food intake is positively associated with cardiovascular health:
findings from Observation of Cardiovascular Risk Factors in..., Nutr Res (2014), http://dx.doi.org/10.1016/j.nutres.2014.04.002
 NUT RI TI O N RESEARC H X X (2014) X X X– X X X 5

4.5
P = .03 P = .006
*
4.4

Cardiovascular Health Score

*
4.3

4.2

4.1

4 Low intake
Medium intake
3.9 High intake

3.8

3.7

3.6
Total low fat milk, yogurt, cheese Total whole fat milk, yogurt, cheese Total dairy food

Dairy food

Fig. 1 – Cardiovascular health score across increasing intakes of total low fat dairy foods, total whole fat dairy foods, and total
dairy foods. Values are mean CHS, adjusted for age, education, sex, total energy intake. Low intake, less than one serve per day;
medium intake, at least 1 to 3 serves per day; and high intake, at least 3 serves per day. Total low fat dairy = low fat milk, yogurt,
and cheese; total whole fat dairy = whole fat milk, yogurt, and cheese; total dairy = milk, yogurt, cheese, dairy desserts, ice
cream, and butter. ⁎ Cardiovascular health score is significantly different from low intake group, P < .05.

total dairy foods than those who did not meet the ideal had significantly higher intakes of dairy products (low fat,
definition (P < .05 for linear trend for all). Those with ideal whole fat, and total) (all P < .01 for linear trend). Physical
levels on both diet scores (ie, those who consumed more activity, BP, total cholesterol, and fasting plasma glucose were
“recommended” foods and fewer “non-recommended” foods) not associated with dairy food intakes.

P = .002
4.7
*

4.5 P = .004 P = .004

Cardiovascular Health Score

* *
P = .04
**
4.3

4.1
Low intake
Medium intake
3.9 High intake

3.7

3.5
Milk Yogurt Cheese Milk Yogurt Cheese Milk Yogurt Cheese Dairy Ice- Butter
desserts cream

Low fat Whole fat Total dairy foods

Dairy product

Fig. 2 – CHS across increasing intakes of milk, yogurt, cheese, dairy desserts, ice cream, and butter. Values are mean
CHS, adjusted for age, education, sex, total energy intake, and remaining dairy products. For milk, yogurt, cheese,
dairy desserts, and butter: low intake, less than one serve per week; medium intake, at least 1 to 5 serves per week;
and high intake, at least 5 serves per week. For ice cream: low intake, non-consumer; and medium intake,
consumer. ⁎CHS is significantly different from low intake group, P < .05. ⁎⁎CHS is significantly different from
medium-intake group, P < .05.

Please cite this article as: Crichton GE, Alkerwi A’, Dairy food intake is positively associated with cardiovascular health:
findings from Observation of Cardiovascular Risk Factors in..., Nutr Res (2014), http://dx.doi.org/10.1016/j.nutres.2014.04.002
 6
findings from Observation of Cardiovascular Risk Factors in..., Nutr Res (2014), http://dx.doi.org/10.1016/j.nutres.2014.04.002
Please cite this article as: Crichton GE, Alkerwi A’, Dairy food intake is positively associated with cardiovascular health:

Table 3 – Total dairy food intakes according to cardiovascular health levels a,b,c

Health metric Total low fat dairy foods d P Total whole fat dairy foods e P Total all dairy foods P
trend trend trend
(Mean serves/day: (Mean serves/day: (Mean serves/day: milk, yogurt, cheese,
milk, yogurt, cheese) milk, yogurt, cheese) dairy desserts, ice cream, butter)

NUTRITIONRESEARCHXX(2014)XXX–XXX
Poor Intermediate Ideal Poor Intermediate Ideal Poor Intermediate Ideal
M SE M SE M SE M SE M SE M SE M SE M SE M SE
f,g f,g
Smoking 0.7 0.05 0.7 0.05 0.7 0.03 .51 1.0 0.06 1.1 0.06 1.3 0.04 <.001 2.3 0.09 2.5 0.09 2.8 0.06 <.001
BMI 0.8 0.05 0.8 0.04 0.6 f,g 0.04 <.001 1.0 0.08 1.2 0.07 1.3 f 0.06 <.001 2.4 0.09 2.6 0.08 2.7 0.07 .041
Physical activity 0.7 0.08 0.8 0.05 0.7 0.03 .82 1.1 0.09 1.2 0.06 1.2 0.04 .12 2.4 0.13 2.6 0.10 2.6 0.05 .19
BP 0.8 0.05 0.8 0.04 0.7 0.05 .34 1.3 0.06 1.2 0.05 1.2 0.05 .37 2.5 0.08 2.6 0.07 2.6 0.09 .23
Cholesterol 0.7 0.06 0.7 0.04 0.8 0.04 .12 1.2 0.07 1.2 0.05 1.2 0.04 .39 2.5 0.10 2.6 0.08 2.6 0.06 .80
Glucose 0.7 0.12 0.7 0.06 0.7 0.03 .94 1.0 0.15 1.2 0.07 1.2 0.03 .10 2.3 0.22 2.5 0.10 2.6 0.05 .19
Non-RFS 0.5 0.10 0.7 0.04 0.8 f,g 0.04 .001 0.9 0.11 1.2 0.05 1.3 f 0.05 .009 2.1 0.17 2.6 f 0.07 2.7 f 0.07 .002
RFS 0.5 0.06 0.7 f 0.03 0.9 f,g 0.05 <.001 0.9 0.07 1.2 f 0.04 1.4 f 0.06 <.001 2.1 0.11 2.6 f 0.06 2.8 f 0.09 <.001
a
Values are mean intakes and SE, of total low fat dairy foods, total whole fat dairy foods, and total dairy foods, in serves p er day, according to level of cardiovascular health for the individual
health metrics.
b
Poor, intermediate, and ideal levels are as defined by the AHA, for adults older than the age of 20 years [2], with exception of diet (RFS and non-RFS).
c
All models adjusted for age, sex, education, and total energy intake.
d
Adjusted for total whole fat dairy foods (milk, yogurt, and cheese).
e
Adjusted for total low fat dairy foods (milk, yogurt, and cheese).
f
Significantly different from poor group.
g
Significantly different from intermediate group.
 NUT RI TI O N RESEARC H X X (2014) X X X– X X X
3.4. Sensitivity analyses
A number of sensitivity analyses were performed. Firstly, the
results remained unchanged after exclusion of study partic-
ipants who reported having modified their diet to either lose
weight or in response to health problems, such as high BP or
cholesterol (n = 195).
To test whether the positive relations between dairy food
intake and CHS held across the full range of dairy intakes, we
performed linear regression analyses (with statistical adjust-
ment for age, education, sex, and total energy intake).
Excluding those with higher intakes (≥3 servings per day),
total dairy food intakes were significantly, positively
associated with the CHS (P = .004). Excluding those with
lower intakes (<3 servings per day), whole fat dairy food
intakes were significantly, positively associated with the
CHS (P = .005).
Because of the strong associations observed between dairy
food intakes and both the RFS and non-RFS, we recalculated
the CHS and excluded diet (both the RFS and non-RFS) from
the total score. Linear regression analyses show that total
dairy food intake was significantly, positively associated with
the modified CHS (excluding diet), with statistical adjustment
for age, sex, education, and total energy intake (P = .01).
Likewise, total whole fat dairy food intake was significantly,
positively associated with the modified CHS (P = .003). Total
low fat dairy food intake was not related.
4. Discussion
To our knowledge, this is one of the first studies to investigate
dairy food consumption in relation to a measure of cardio-
vascular health, indexed by a constellation of health factors
and behaviors. Total dairy food intake was positively associ-
ated with cardiovascular health, as indicated by a higher CHS.
Specifically, higher intakes of whole fat milk, total yogurt, and
total cheese were independently associated with better
cardiovascular health. Those who consumed at least 5
servings per week of milk or yogurt had a significantly higher
CHS than those who consumed these products less frequent-
ly, irrespective of age, sex, level of education, total energy
intake, and intake of other dairy products. No associations
were observed between intakes of dairy desserts, ice cream, or
butter with the CHS. Dairy foods provide several important
nutrients that are beneficial for bone, cardiovascular,
and overall health. In this study, milk, yogurt, and cheese
intakes—but not dairy desserts, ice cream, or butter—were
associated with better cardiovascular health, thus suggesting
that not all dairy products are equally beneficial in promoting
cardiovascular health. The findings support our previous work
that focused on a sample of US adult participants in the
Maine-Syracuse Longitudinal Study. Similar positive associa-
tions were found between intakes of yogurt, milk, and total
dairy food intake with cardiovascular health, as measured
using the same CHS. In particular, yogurt consumption was
positively associated with ideal levels on a number of the
individual metrics, including BP, physical activity, and the 2
diet scores (submitted and under review). Another recent US
study has shown associations between higher yogurt intakes
Please cite this article as: Crichton GE, Alkerwi A’, Dairy food intake is positively associated with cardiovascular health:
findings from Observation of Cardiovascular Risk Factors in..., Nutr Res (2014), http://dx.doi.org/10.1016/j.nutres.2014.04.002
7
and lower levels of systolic BP, glucose, and triglycerides [29].
This study similarly compared yogurt intakes in relation to
intakes of healthy foods as recommended by the American
Dietary Guidelines and found that yogurt consumers had
higher intakes of fruit and vegetables, nuts and seeds, and fish
and whole grains compared with nonconsumers and there-
fore better diet quality scores [29]. Inverse associations have
also been shown between yogurt consumption and weight
gain [30], central obesity and the metabolic syndrome [31], and
type 2 diabetes mellitus [32]. Together, these findings suggest
that yogurt may be a particularly favorable dairy food. Yogurt
is an excellent source of vitamin B and minerals, including
calcium, zinc, potassium, and magnesium, which are essen-
tial factors for a wide variety of metabolic functions.
Furthermore, the probiotic bacteria contained in yogurt may
be an important component, not found in other dairy
products, that may enhance the immune response and
increase resistance to immune-related diseases [33].
Interestingly, low fat dairy intake was not associated with
the global CHS but was associated with “higher” BMI. Many
countries continue to recommend the consumption of low fat
dairy products [15,19,34]. Most European countries have some
form of Food-Based Dietary Guidelines, which are simple
messages on healthy eating that give short and clear
information about what a person should be eating in terms
of foods rather than nutrients, for example, “eat low fat dairy
products [34].” The Dietary Guidelines for Luxembourg, with
regard to foods to consume more frequently and foods to
limit, are consistent with the recommendations of the Dietary
Guidelines for Americans and similarly recommend the
consumption of at least 3 portions per day of milk or dairy
products [19,28]. Nearly one-third of the present study sample
(31%) met this guideline. Despite the recommendations to
choose low fat dairy products and the negative image that
whole fat dairy foods have typically received due to its
saturated fat content, a substantial amount of recent research
is in fact providing opposing evidence [6,35]. Our findings lend
support to this body of research. In an extensive review of 16
studies examining relationships between the consumption of
high fat dairy foods, obesity, and cardiometabolic risk, Kratz et
al [5] firstly concluded that high fat dairy consumption is
inversely associated with obesity risk. Interestingly, none of
the studies found that low fat dairy intake was inversely
associated with obesity risk. Secondly, they concluded that
the observational evidence to date does not support the
notion that dairy fat has an adverse effect on metabolic health
but rather may have a protective effect [5]. These findings are
largely consistent with those of Huth and Park [3], who, based
on a limited number of prospective cohort studies, concluded
that there is little evidence of an association between full fat
dairy product intakes and risk of coronary heart disease or
stroke. Another dose-response meta-analysis by Soedamah-
Muthu et al [10] indicated no association between total high
fat dairy intakes and coronary heart disease.
One may argue that the results in the present study are not
altogether surprising because diet modification, such as replac-
ing whole fat products with low fat, may occur predominantly in
response to poor health or illness. However, after excluding this
proportion of the study sample who reported having modified
their dietto either lose weight or inresponse to health problems,
8 NUT RI TI O NRESEARC HX X(2014)X X X– X X X
such as high BP or cholesterol (195 participants), the results
remained unchanged. We have also demonstrated that whole
fat dairy food intake is associated with other positive lifestyle
behaviors. Because of the strong associations between dairy
food intake and ideal health on the 2 diet scores, it could be
postulated that the relation between dairy food intake and total
CHS may be largely due to this association. However, sensitivity
analyses excluding the RFS and non-RFS from the CHS showed
that positive associations between intakes of total dairy foods
and total whole fat milk, cheese, and yogurt with the modified
CHS remained.
The present study used a large, newly collected sample
that was nationally representative of Luxembourg, a small but
centrally located European country. Additional strengths
include the use of both the RFS and non-RFS for the diet
metric [17,18], with the exclusion of dairy foods. They are
similar to Food-Based Dietary Guidelines, which focus on
whole foods and capture more variety than that used in the
AHA diet metric [2]. Most importantly, we considered the
consumption of dairy products in relation to both “traditional”
cardiovascular risk factors (glucose, cholesterol, and BP) and
lifestyle behaviors (smoking, physical activity, and diet, which
are reflected by BMI), as opposed to CVD or mortality risk.
Aside from our findings in the Maine-Syracuse Longitudinal
Study [36], we are unaware of any other study to have related
dairy food intake to the ideal cardiovascular health construct,
especially outside the United States.
Some limitations should be noted. The study was cross-
sectional and therefore does not permit any causal inference
regarding dairy food intake on cardiovascular health or CVD
risk. Residual confounding cannot be ruled out as a possible
explanation for the observed findings. Dietary, smoking, and
physical activity measures were reliant upon self-report, and
therefore, this is subject to the aberrant biases involved in any
self-reported data. As in all nutrition research, dietary
questionnaires are subject to memory biases, likely resulting
in both over- and under-reporting.
Overall, as hypothesized, higher total dairy food intake was
positively associated with cardiovascular health, as indexed by
7 health behaviors and factors. This relationship was partic-
ularly evident for whole fat dairy products, namely, milk,
yogurt, and cheese. The findings of the present study concur
with recent research suggesting that the consumption of
whole fat dairy products does not have an adverse influence on
CVD risk and thus, have value for public health recommenda-
tions. It is added evidence to support the concept that daily
dairy food intake may be part of a healthy lifestyle. Whole fat
dairy food intake was strongly correlated with other positive
health behaviors including non-smoking, better dietary in-
takes, and normal BMI. Future longitudinal studies and
intervention trials are needed to substantiate these findings.
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Please cite this article as: Crichton GE, Alkerwi A’, Dairy food intake is positively associated with cardiovascular health:
findings from Observation of Cardiovascular Risk Factors in..., Nutr Res (2014), http://dx.doi.org/10.1016/j.nutres.2014.04.002