N UTR IT ION RE S EA RCH XX ( 2 0 14 ) XXX–X XX
Available online at www.sciencedirect.com
ScienceDirect www.nrjournal.com
Dairy food intake is positively associated with cardiovascular health: findings from Observation of Cardiovascular Risk Factors in Luxembourg study☆ Georgina E. Crichton a, b,⁎, Ala’a Alkerwi b a b
Nutritional Physiology Research Centre, University of South Australia, Adelaide, Australia Centre de Recherche Public Santé, Centre d’Etudes en Santé, Strassen, Grand Duchy of Luxembourg
ARTI CLE I NFO
A BS TRACT
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: [email protected], [email protected] (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
N UTR IT ION RE S EA RCH XX ( 2 0 14 ) XXX–X XX
1.
Introduction
Cardiovascular disease (CVD) causes more than 4 million deaths in Europe and is estimated to cost almost €196 billion per year [1]. The American Heart Association (AHA) recently defined a construct of “ideal cardiovascular health” comprising 7 health metrics: not smoking, engaging in sufficient physical activity, consuming a healthy diet, maintaining a normal body mass index (BMI), and having optimal levels of total cholesterol, blood pressure (BP), and fasting blood glucose [2]. Diet is an integral part of CVD prevention. However, the evidence regarding the intake of dairy products, particularly with regard to the fat content of dairy and CVD risk is inconsistent. Some studies have failed to find an increased risk of CVD [3] or CVD mortality [4] associated with the intake of dairy products, regardless of fat content. Other studies suggest that the consumption of 3 or more servings per day is associated with a reduced risk of CVD [5-7]. However, high fat dairy intake has also been associated with an increased risk of CVD mortality [8]. A recent meta-analysis of randomized controlled trials concluded that increasing dairy food intakes did not significantly impact cardiometabolic risk factors [9]. Few epidemiological studies have examined dairy food intake (including both low and high fat products) in relation to a constellation of health factors and behaviors, such as the AHA construct of cardiovascular health. Most studies and reviews have focused on risk for “disease” and/or cardiovascular “mortality” risk [3-8,10]. As the treatment for and survival from acute cardiovascular conditions improves, the number of patients living with chronic disease will continue to increase [11]. Simple lifestyle changes that may impact the individual risk factors for CVD will become increasingly important for cost-benefit prevention strategies. Encompassing 7 health factors and behaviors, the present study aimed to explore the relationship between dairy food consumption and cardiovascular health among adults in the Observation of Cardiovascular Risk Factors in Luxembourg (ORISCAV-LUX) survey. First, it was hypothesized that greater total dairy food consumption would be associated with better global cardiovascular health, as indicated by a higher cardiovascular health score (CHS). Second, it was hypothesized that ideal levels of individual health metrics, particularly the health behaviors, would be associated with greater total dairy food intakes. To test these hypotheses, the research objectives were as follows: (1) to assess the relationship between the CHS (as a continuous variable) across increasing intakes of total low fat, total whole fat, and all dairy foods; (2) to compare the CHS across increasing intakes of individual dairy foods; and (3) to explore relationships between the individual health metrics and total dairy food intakes (low fat, whole fat, and all dairy foods).
2.
Methods and materials
2.1.
Study population
The present study used data from the ORISCAV-LUX survey. This was a nationwide, cross-sectional study conducted
between 2007 and 2009 that was designed to gather information on the prevalence of cardiovascular risk factors among the general adult population of Luxembourg. A random sample of 1432 individuals, stratified by sex, age (18-69 years), and district of residence completed the recruitment procedure [12,13]. After the elimination of those subjects with incomplete information on components of cardiovascular health or diet, data were available for 1352 subjects for the current study. Detailed information about the study design and sampling methods has been published elsewhere [13]. All participants provided informed written consent. The ORISCAV-LUX was approved by the National Research Ethics Committee and the National Commission for Private Data Protection.
2.2.
Dietary assessment
2.2.1.
Dairy food intakes
Dietary intake was assessed using a semiquantified food frequency questionnaire, which assessed the frequency of consumption of 134 items over the previous 3 months [14]. Participants were asked how often they consumed one standardized portion of each food (eg, one medium cup [125 mL] of milk). The 6 response categories ranged from “never or rarely” to “2 or more times per day.” Dairy products included in the questionnaire were milk (skim, semi-skim, and whole), cheese (low fat and regular), yogurt (low fat and regular), dairy desserts, ice cream, and butter. To facilitate comparison between the different dairy products, the responses were recalculated into servings per day that were based on standard serving sizes (250 mL of milk; 125 g of yogurt, ice cream, and dairy desserts; 50 g of cheese; and 30 g of butter) [15,16]. For research objectives, dairy food intakes were classified into 3 groups: (1) total low fat dairy foods (total consumption of low-fat milk, yogurt, and cheese); (2) total whole fat dairy foods (total consumption of whole fat milk, yogurt, and cheese); and (3) total dairy foods (total consumption of both low and whole fat milk, yogurt, and cheese as well as dairy desserts, ice cream, and butter).
2.2.2.
Calculation of healthy diet metric
Two food scores were calculated for the diet metric, a Recommended Food Score (RFS) [17] and a non-Recommended Food Score (non-RFS) [18]. These scores were used to capture a more detailed measure of dietary intakes and variety. Based on the recommendations of the 2010 Dietary Guidelines for Americans, the RFS comprised 17 food items [19]. Foods included fruit, vegetables, legumes, whole grain cereal products, fish and nuts— items similar to those used previously [17,20]. One point was assigned for consumption of any of the recommended foods at least once per week; otherwise, 0 points were given [17]. A total RFS out of 17 was calculated, with a higher score indicating a 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 recommended [19], such as processed meats, refined grains, solid fats and added sugars, and alcohol. Consumption of non-recommended foods at least 2 to 4 times per week was assigned a score of 1; otherwise, 0 points were assigned [20,21]. A total non-RFS out of 11 was calculated, with 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
N UTR IT ION RE S EA RCH XX ( 2 0 14 ) XXX–X XX
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 measurements, 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 deciliter), 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 (OHEM-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 International 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/m 2; 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 of 0 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
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 therefore better dietary practices. Furthermore, our past research has shown positive associations between dairy food consumption 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 (
Available online at www.sciencedirect.com
ScienceDirect www.nrjournal.com
Dairy food intake is positively associated with cardiovascular health: findings from Observation of Cardiovascular Risk Factors in Luxembourg study☆ Georgina E. Crichton a, b,⁎, Ala’a Alkerwi b a b
Nutritional Physiology Research Centre, University of South Australia, Adelaide, Australia Centre de Recherche Public Santé, Centre d’Etudes en Santé, Strassen, Grand Duchy of Luxembourg
ARTI CLE I NFO
A BS TRACT
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: [email protected], [email protected] (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
N UTR IT ION RE S EA RCH XX ( 2 0 14 ) XXX–X XX
1.
Introduction
Cardiovascular disease (CVD) causes more than 4 million deaths in Europe and is estimated to cost almost €196 billion per year [1]. The American Heart Association (AHA) recently defined a construct of “ideal cardiovascular health” comprising 7 health metrics: not smoking, engaging in sufficient physical activity, consuming a healthy diet, maintaining a normal body mass index (BMI), and having optimal levels of total cholesterol, blood pressure (BP), and fasting blood glucose [2]. Diet is an integral part of CVD prevention. However, the evidence regarding the intake of dairy products, particularly with regard to the fat content of dairy and CVD risk is inconsistent. Some studies have failed to find an increased risk of CVD [3] or CVD mortality [4] associated with the intake of dairy products, regardless of fat content. Other studies suggest that the consumption of 3 or more servings per day is associated with a reduced risk of CVD [5-7]. However, high fat dairy intake has also been associated with an increased risk of CVD mortality [8]. A recent meta-analysis of randomized controlled trials concluded that increasing dairy food intakes did not significantly impact cardiometabolic risk factors [9]. Few epidemiological studies have examined dairy food intake (including both low and high fat products) in relation to a constellation of health factors and behaviors, such as the AHA construct of cardiovascular health. Most studies and reviews have focused on risk for “disease” and/or cardiovascular “mortality” risk [3-8,10]. As the treatment for and survival from acute cardiovascular conditions improves, the number of patients living with chronic disease will continue to increase [11]. Simple lifestyle changes that may impact the individual risk factors for CVD will become increasingly important for cost-benefit prevention strategies. Encompassing 7 health factors and behaviors, the present study aimed to explore the relationship between dairy food consumption and cardiovascular health among adults in the Observation of Cardiovascular Risk Factors in Luxembourg (ORISCAV-LUX) survey. First, it was hypothesized that greater total dairy food consumption would be associated with better global cardiovascular health, as indicated by a higher cardiovascular health score (CHS). Second, it was hypothesized that ideal levels of individual health metrics, particularly the health behaviors, would be associated with greater total dairy food intakes. To test these hypotheses, the research objectives were as follows: (1) to assess the relationship between the CHS (as a continuous variable) across increasing intakes of total low fat, total whole fat, and all dairy foods; (2) to compare the CHS across increasing intakes of individual dairy foods; and (3) to explore relationships between the individual health metrics and total dairy food intakes (low fat, whole fat, and all dairy foods).
2.
Methods and materials
2.1.
Study population
The present study used data from the ORISCAV-LUX survey. This was a nationwide, cross-sectional study conducted
between 2007 and 2009 that was designed to gather information on the prevalence of cardiovascular risk factors among the general adult population of Luxembourg. A random sample of 1432 individuals, stratified by sex, age (18-69 years), and district of residence completed the recruitment procedure [12,13]. After the elimination of those subjects with incomplete information on components of cardiovascular health or diet, data were available for 1352 subjects for the current study. Detailed information about the study design and sampling methods has been published elsewhere [13]. All participants provided informed written consent. The ORISCAV-LUX was approved by the National Research Ethics Committee and the National Commission for Private Data Protection.
2.2.
Dietary assessment
2.2.1.
Dairy food intakes
Dietary intake was assessed using a semiquantified food frequency questionnaire, which assessed the frequency of consumption of 134 items over the previous 3 months [14]. Participants were asked how often they consumed one standardized portion of each food (eg, one medium cup [125 mL] of milk). The 6 response categories ranged from “never or rarely” to “2 or more times per day.” Dairy products included in the questionnaire were milk (skim, semi-skim, and whole), cheese (low fat and regular), yogurt (low fat and regular), dairy desserts, ice cream, and butter. To facilitate comparison between the different dairy products, the responses were recalculated into servings per day that were based on standard serving sizes (250 mL of milk; 125 g of yogurt, ice cream, and dairy desserts; 50 g of cheese; and 30 g of butter) [15,16]. For research objectives, dairy food intakes were classified into 3 groups: (1) total low fat dairy foods (total consumption of low-fat milk, yogurt, and cheese); (2) total whole fat dairy foods (total consumption of whole fat milk, yogurt, and cheese); and (3) total dairy foods (total consumption of both low and whole fat milk, yogurt, and cheese as well as dairy desserts, ice cream, and butter).
2.2.2.
Calculation of healthy diet metric
Two food scores were calculated for the diet metric, a Recommended Food Score (RFS) [17] and a non-Recommended Food Score (non-RFS) [18]. These scores were used to capture a more detailed measure of dietary intakes and variety. Based on the recommendations of the 2010 Dietary Guidelines for Americans, the RFS comprised 17 food items [19]. Foods included fruit, vegetables, legumes, whole grain cereal products, fish and nuts— items similar to those used previously [17,20]. One point was assigned for consumption of any of the recommended foods at least once per week; otherwise, 0 points were given [17]. A total RFS out of 17 was calculated, with a higher score indicating a 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 recommended [19], such as processed meats, refined grains, solid fats and added sugars, and alcohol. Consumption of non-recommended foods at least 2 to 4 times per week was assigned a score of 1; otherwise, 0 points were assigned [20,21]. A total non-RFS out of 11 was calculated, with 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
N UTR IT ION RE S EA RCH XX ( 2 0 14 ) XXX–X XX
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 measurements, 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 deciliter), 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 (OHEM-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 International 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/m 2; 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 of 0 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
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 therefore better dietary practices. Furthermore, our past research has shown positive associations between dairy food consumption 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 (
