Intake of different types of dairy and the impact on type 2 diabetes risk in Dutch adults

Dr. Ir. EM Brouwer-Brolsma

Division of Human Nutrition, Wageningen University

Health effects of cheese/dairy matrix

Outline

Background – dairy and type 2 diabetes

The Rotterdam Study

• Aim

• Dairy product classification

• Assessment of type 2 diabetes

• Results

• Our findings in a broader context

The next step: analyses within the LifeLines cohort study

Overweight & chronic diseases

Risk factors: ±23-31%* lifestyle!

*Estimation RIVM

Dietary factors

DAIRY

Why dairy?

For instance: Calcium → lipogenesis,

inflammation, oxidativestress, insulin secretion, and insulin sensitivity

Whey protein → satietyrelated hormones, lipidmetabolism, and insulinsecretion

Vitamin K → inflammation, and insulinsensitivity

For instance Saturated fats

cholesterol levels, blood pressure

Added sugars insulin sensitivity

Sodium blood pressure

Products instead of single nutrients

Cohort studies on dairy and T2DM

#20

#11 low-fat dairy

#9 high-fat dairy

#9 milk

#5 low-fat milk

#6 high-fat milk

#9 yoghurt

#9 cheese

#17 total dairy

Dairy consumption and T2DM: the gap

The impact of total dairy consumption on the development of T2DM has

already been investigated in several prospective studies, but results are

inconclusive

Literature on a broad range of individual dairy products in one population is

limited (e.g. low vs. high fat products, product type (e.g. milk, yogurt,

buttermilk, cheese, butter), and processing type (fermented, non-fermented)

Goal of this study

To investigate associations between a broad variety of dairy products and the

development of type 2 diabetes in the Rotterdam Study.

The Rotterdam Study

2974 men and women, ≥55 years, followed for ±10y

Dietary intake: 170-item validated FFQ

Type 2 diabetes: information from general practitioners, pharmacies’ databases, and follow-up examinations were used to identify cases of diabetes.

Dairy consumption subgroupsDefinition of the dairy product groups

Dairy product group

Included dairy products

Total dairy All dairy products, except butter. Skimmed dairy

All milk and milk products with a fat content ≤0.5%, cheeses with a fat content ≤10%, and curd cheeses and cream cheeses with a fat content <10%.

Semi-skimmed dairy

All milk and milk products with a fat content ≥1.50% - ≤1.80%, cheeses with a fat content >10% - <50%, and curd cheeses and cream cheeses with a fat content ≥10% - ≤34%.

Full-fat dairy

All milk and milk products with a fat content >1.80%, cheeses with a fat content ≥50%, and curd cheeses and cream cheeses with a fat content ≥35%.

Milk All types of milk, including raw milk, pasteurised milk, fluid milk, milk powder, plain milk, and chocolate milk.

Yogurt All types of yogurt, including plain yogurt, and flavoured/fruit yogurt. Buttermilk All types of buttermilk. Curd cheese All types of curd cheese, including plain curd cheese, and flavoured/fruit curd cheese. Cheese All types of cheese, including plain cheeses, cheeses with cumin, sodium reduced

cheeses, hard cheeses, and cheese spreads. Butter All types of (unsalted) butter. Fermented dairy All types of yogurt, curd cheese, buttermilk, and cheese. Non-fermented dairy All types of milk, and cream.

1

Statistical analyses & interpretation

By quartile of dairy intake: lowest quartile served as reference

Cox proportion hazards analyses Hazard Ratio (HR)

Example: HR 0.80 (95% CI: 0.60-0.90)

Note: in this presentation the fully adjusted models are shown, incl.

age, sex (model 1), alcohol, smoking, education, physical activity (model 2), total energy intake,

energy adjusted meat intake, energy-adjusted fish intake (model 3), and BMI (model 4).

20% risk reduction0.60-0.90 CI below 1.0 statistically significant risk reduction

Results – general characteristics

65±7 y26±3 kg/m2

40%

22%

22% family history T2DM 398 g/d (IQR 259-559)

10±4 y

393 T2DM cases

Results – total and split for fat contentHazard Ratios (95% CI) by dairy quartile in g/day (n=2974)

Q1 Q2 Q3 Q4 P for trend

Total dairy ≤258 259-397 398-557 ≥558

T2DM cases/total n 108/746 91/742 91/738 103/748

Fully adjusted model 1.0 0.81 (0.61-1.08) 0.83 (0.62-1.11) 0.93 (0.70-1.23) 0.76

Skimmed dairy ≤13 14-93 94-224 ≥225

T2DM cases/total n 95/753 101/732 97/751 100/738

Fully adjusted model 1.0 1.11 (0.83-1.47) 0.99 (0.74-1.32) 1.01 (0.76-1.35) 0.80

Semi-skimmed dairy ≤7.7 7.8-63 64-218 ≥219

T2DM cases/total n 92/747 103/740 102/742 96/745

Fully adjusted model 1.0 1.00 (0.73-1.39) 0.99 (0.73-1.34) 0.93 (0.69-1.26) 0.57

Full-fat dairy ≤59 60-103 104-168 ≥169

T2DM cases/total n 108/751 88/735 103/746 94/742

Fully adjusted model 1.0 0.74 (0.55-1.01) 0.88 (0.66-1.19) 0.96 (0.71-1.29) 0.67Models are adjusted for age (years, continuous), sex (men/women), alcohol (categorical), smoking (categorical), education (categorical), physical activity (MET/hours, continuous), total energyintake (kcal/day, continuous), energy adjusted meat intake (g/day, continuous), and energy-adjusted fish intake (g/day, continuous), and BMI (kg/m2, continuous).

Results – processing type

Hazard Ratios (95% CI) by dairy quartile in g/day (n=2974)

Q1 Q2 Q3 Q4 P for trend

Non-fermented dairy ≤89 90-205 206-343 ≥344

T2DM cases/total n 102/742 97/745 92/743 102/744

Fully adjusted model 1.0 0.89 (0.67-1.19) 0.86 (0.64-1.15) 1.01 (0.76-1.34) 0.85

Fermented dairy ≤59 60-148 149-255 ≥256

T2DM cases/total n 92/743 103/744 103/744 95/743

Fully adjusted model 1.0 1.13 (0.85-1.51) 1.08 (0.81-1.45) 0.98 (0.73-1.32) 0.65

Models are adjusted for age (years, continuous), sex (men/women), alcohol (categorical), smoking (categorical), education(categorical), physical activity (MET/hours, continuous), total energy intake (kcal/day, continuous), energy adjusted meat intake(g/day, continuous), and energy-adjusted fish intake (g/day, continuous), and BMI (kg/m2, continuous).

Results – product type (1)Hazard Ratios (95% CI) by dairy quartile in g/day (n=2974)

Q1 Q2 Q3 Q4 P for trend

Milk ≤65 66-180 181-315 ≥316

T2DM cases/total n 96/739 94/745 102/747 101/743

Fully adjusted model 1.0 0.93 (0.69-1.24) 1.00 (0.75-1.34) 1.04 (0.78-1.39) 0.60

Yogurt ≤1 2-45 46-108 ≥109

T2DM cases/total n 113/743 88/744 94/744 98/743

Fully adjusted model 1.0 0.76 (0.57-1.02) 0.84 (0.63-1.12) 0.86 (0.65-1.14) 0.68

Buttermilk 0 0-1 2-140 ≥141

T2DM cases/total n 86/739 99/751 111/741 97/743

Fully adjusted model 1.0 1.08 (0.77-1.51) 1.15 (0.83-1.60) 1.01 (0.73-1.39) 0.62

Models are adjusted for age (years, continuous), sex (men/women), alcohol (categorical), smoking (categorical), education(categorical), physical activity (MET/hours, continuous), total energy intake (kcal/day, continuous), energy adjusted meat intake(g/day, continuous), and energy-adjusted fish intake (g/day, continuous), and BMI (kg/m2, continuous).

Results – product type (2)Hazard Ratios (95% CI) by dairy quartile in g/day (n=2974)

Q1 Q2 Q3 Q4 P for trend

Curd cheese/quark No (0) Yes (>0)

T2DM cases/total n 182/1324 211/1650

Fully adjusted model 1.0 1.01 (0.78-1.31)

Cheese ≤23 24-33 34-46 ≥47

T2DM cases/total n 94/746 91/746 97/740 111/745

Fully adjusted model 1.0 0.92 (0.68-1.24) 0.94 (0.70-1.25) 1.08 (0.81-1.43) 0.50

Butter No (0) Yes (>0)

T2DM cases/total n 124/956 269/2018

Fully adjusted model 1.0 0.96 (0.73-1.27)

Models are adjusted for age (years, continuous), sex (men/women), alcohol (categorical), smoking (categorical), education(categorical), physical activity (MET/hours, continuous), total energy intake (kcal/day, continuous), energy adjusted meat intake(g/day, continuous), and energy-adjusted fish intake (g/day, continuous), and BMI (kg/m2, continuous).

Thus.....

No evidence for a beneficial or adverse association between dairy consumption and

the development of T2DM, which was monitored for on average 10 years

Discussion

Assessment of dairy intake: 170-item FFQ

validated for calcium (r=0.72) and protein (r=0.66) against 15 24-h recalls

broad range of dairy products

administered only once

Dutch population: relatively high dairy consumption

Relatively small sample size – replication is warranted!

The next step.....LifeLines Cohort Study

Ca. n=115,000 men and women, ≥18 years

Dietary intake: FFQ

Anthropometric measures: weight, BMI, waist circumference, waist-to-hip ratio

Glucose metabolism: fasting glucose, HbA1c, diabetes prevalence

LifeLines Cohort Study Dairy product classification

Total dairy All dairy products mentioned below

Skimmed dairy All types skimmed milk and yogurt, buttermilk, and flavoured yogurt drinks

Semi-skimmed dairy All types semi-skimmed milk and low-fat cheeses

Full-fat dairy All types of full-fat milk, yogurt, and cheese, cream, milk-based ice cream, chocolate milk, full-

fat cheese

Milk All types of milk, including liquid plain milk, liquid coffee milk, creamer, and chocolate milk.

Yogurt All types of yogurt, including plain yogurt, and flavoured/fruit yogurt.

Buttermilk All types of buttermilk.

Curd cheese/quark All types of curd cheese/quark, including plain and flavoured/fruit types.

Cheese All types of cheese, including hard cheeses, soft cheeses, full-fat cheeses, fat reduced

cheeses, cheese spreads, and foreign cheeses.

Custard All types of custard

Flavoured yogurt drinks All types of flavoured yogurt drinks

Fermented dairy All types of yogurt, curd cheese/quark, buttermilk, cheese, and flavoured yogurt drinks

Non-fermented dairy All types of milk, custard, porridge, milk-based ice cream, and cream.

Lifelines – general characteristics

45±13 y26±4 kg/m2

42%

2386 T2DM cases

Q1 Q2 Q3 Q4 Q5

≤197 197-282 283-367 368-479 ≥480

The next step..... analysesLifeLines Cohort Study

Analysing associations between dairy intake and measures of glucose tolerance(i.e. fasting plasma glucose, HbA1c, and T2DM).

Analysing associations between dairy intake and anthropometric measures (i.e. body weight, BMI, waist circumference, and waist-to-hip ratio).

Stratifying associations between dairy intake, measures of glucose tolerance, and antropometric measures according to age (<65 and ≥65 years), sex (men/women), (and BMI (<25 and ≥25 kg/m2))

Results...LifeLines Cohort Study

Will follow soon...

First paper is planned to be submitted in the first half of 2017!

Thank you!

Models without and with BMI (1)Q1 Q2 Q3 Q4 P for trend

Total dairy, g/day ≤258 259-397 398-557 ≥558

Median 174 327 472 682

T2DM cases/total n 108/746 91/742 91/738 103/748

Model 3 1.0 0.84 (0.63-1.12) 0.87 (0.65-1.16) 0.99 (0.74-1.32) 0.90

Model 4 1.0 0.81 (0.61-1.08) 0.83 (0.62-1.11) 0.93 (0.70-1.23) 0.76

Skimmed dairy, g/day ≤13 14-93 94-224 ≥225

Median 1 48 150 336

Model 3 1.0 1.11 (0.84-1.48) 1.02 (0.76-1.36) 1.07 (0.80-1.43) 0.85

Model 4 1.0 1.11 (0.83-1.47) 0.99 (0.74-1.32) 1.01 (0.76-1.35) 0.80

Semi-skimmed dairy,

g/day

≤7.7 7.8-63 64-218 ≥219

Median 0 24 151 344

T2DM cases/total n 92/747 103/740 102/742 96/745

Model 3 1.0 1.02 (0.74-1.41) 1.02 (0.76-1.38) 0.98 (0.73-1.32) 0.84

Model 4 1.0 1.00 (0.73-1.39) 0.99 (0.73-1.34) 0.93 (0.69-1.26) 0.57

Full-fat dairy, g/day ≤59 60-103 104-168 ≥169

Median 32 82 129 261

T2DM cases/total n 108/751 88/735 103/746 94/742

Model 3 1.0 0.74 (0.55-1.00) 0.88 (0.66-1.19) 0.90 (0.67-1.20) 0.96

Model 4 1.0 0.74 (0.55-1.01) 0.88 (0.66-1.19) 0.96 (0.71-1.29) 0.67

Models without and with BMI (2)

Q1 Q2 Q3 Q4 P for trend

Total non-fermented

dairy, g/day

≤89 90-205 206-343 ≥344

Median 37 142 265 471

T2DM cases/total n 102/742 97/745 92/743 102/744

Model 3 1.0 0.89 (0.67-1.19) 0.87 (0.65-1.17) 1.02 (0.77-1.35) 0.76

Model 4 1.0 0.89 (0.67-1.19) 0.86 (0.64-1.15) 1.01 (0.76-1.34) 0.85

Fermented dairy, g/day ≤59 60-148 149-255 ≥256

Median 34 100 190 370

T2DM cases/total n 92/743 103/744 103/744 95/743

Model 3 1.0 1.17 (0.88-1.57) 1.13 (0.85-1.50) 1.06 (0.79-1.43) 0.97

Model 4 1.0 1.13 (0.85-1.51) 1.08 (0.81-1.45) 0.98 (0.73-1.32) 0.65