lÁcteos y obesidad, diabetes, hipertensiÓn y sÍndrome … · 2019. 3. 25. · yogurt and...

LÁCTEOS Y OBESIDAD, DIABETES, HIPERTENSIÓN Y SÍNDROME METABÓLICO:

Estudios epidemiológicos y mecanismos protectores

Jordi Salas-SalvadóCatedrático de Nutrición

Unidad de Nutrición HumanaUniversidad Rovira i Virgili

Conflict of Interest Disclosure

• Relationships with commercial interests:

• Non-paid member of the Scientific Committee of the International Nut and Dried Fruit Foundation.

• Member of the Executive Committee of the Instituto Danone-Spain

• Grants/Research Support: American Pistachio Growers,

International Nut and Dried Fruit Foundation.

• Speakers Bureau/Honoraria: Nuts for Life, Danone, Eroski, Dos

Pinos.

• Consulting Fees: Danone.

Mitigating potential biasThe PREDIMED sponsors had no role in the design and conduct of thestudy: collection, management, analysis, and interpretation of the data:preparation, review or approval of the published manuscripts.

DAIRY PRODUCTS

OBESITY

CANCER

RISK

CARDIOVASCULAR DISEASEDIABETES

METABOLIC

SYNDROME

Minerals

Vitamins

Protein

calcium

magnesium

potassium

phosphate

zinc

Vit. A

Vit. D

Vit. B2, B3, B6, B12

Vit. K2

Probiotic bacteria

“fermented dairy products”

OSTOPOROSIS

HC “lactose”

Fat

DAIRY PRODUCTS

Nutritional concerns:Rich in natural trans fatty acids

Rich in saturated fatty acidsRich in salt (ie. cheese)

Rich in added sugar (some yogurts and processed dairy foods)Irrational beliefs that lead to a decrease in consumption:

“Humans are the unique animals that consume dairy products through the life”

DAIRY PRODUCTS

In the last years some guidelines recommend to consume low-fat dairy

products or to limit them

DAIRY PRODUCTS

Astrup A. Yogurt and dairy product consumption to prevent cardiometabolic diseases: epidemiologic and experimental studies. Am J Clin Nutr. 2014.

“The consumption of yogurt and other dairy products, in observational studies is associated with a reduced risk of weight gain and obesity as well as of CVD, and these findings are, in part, supported by randomized trials”.

Recent published evidences support the idea that dairy products can be beneficial (or not harmful) for several chronic metabolic conditions and CVD.

• Generally the literature agrees that dairy products are neutral or beneficial to human health asevidenced by several meta-analyses and randomised, controlled trials.

• Not all SFA are created equal and that the presence of specific fatty acids (C14:0,C15:0, C17:0 andtrans-palmitoleic) in circulation are associated with a lower incidence of several cardiometabolicdiseases, however some may simply be markers of dairy intake.

• The dairy food matrix also plays a major role in nutritional research.

• Dairy products contain a high SFA content, their consumption induces a positive or neutral effecton human cardiovascular health

Consumers can continue to moderately consume full-fat dairy products as part of a healthy and

balanced lifestyle, however fermented dairy products would be preferential for optimum nutrient

intake and potential cardiovascular health benefits.

DIABETES: THE GLOBAL BURDEN

More than 387 million people in the word have diabetes.By 2030 is expected this will have risen to 592 million people.

• The prevalence of T2DM is increasing in parallel to the obesity epidemics.

• T2DM is a potent risk factor for CVD, blindness, renal failure, and lower limb amputation, decreasing quality of life.

• T2DM is responsible of the 5 % of the total mortality.

• In the next 10 years is expected that mortality by diabetes will increase by 50%.

DIABETES: THE GLOBAL BURDEN

OXIDATION

INFLAMMATION

Endothelialdysfunction

Insulin resistance/secretion

DIABETES

Geneticbackground

Low glycemic index

Fiber

MUFA / PUFA

Magnesium

Antioxidants

(-)

(-)

(-)

(-)

(-)

High glycemic index

SFA

TFA(+)

(+)

(+)

MECHANISMS

Salas-Salvadó et al, NMCD 2011

(-)

Heme iron(+)

“six meta-analysis of prospective studies have shown a decrased

risk of diabetes in those individuals with a higher consumption of

dairy products”.

DAIRY PRODUCTS AND DIABETES

0.90 0.95 1.05 1.10

Total dairy (n=17) (per 200g/d)

Low-fat dairy (n=13)(per 200g/d)

High-fat dairy (n=13)(per 200g/d)

Total milk (n=12)(per 200g/d)

Low-fat milk (n=7)(per 200g/d)

Cheese (n=13)(per 10g/d)

Number

populationsHeterogenity test

I2 P-vaue

66.4 <0.001

High-fat milk (n=9)(per 200g/d)

68.0 <0.001

51.6 0.016

57.4 0.007

71.6 0.002

84.1 <0.001

61.7 0.002

Consumption of dairy foods and diabetes incidence: a dose-responsemeta-analysis of observational studies

Lieke Gijsbers et al., Am J Clin Nutr 2016

“This dose-response meta-analysis of observational

studies suggest a posible role for dairy foods in the

prevention of type 2 diabetes”

Results should be considered in the context of the

observed heterogeneity

22 cohort studies 579,832 individuals and 43,118 T2D cases)

RR


Food groups and risk of type 2 diabetes mellitus: a systematic review and meta-analysis of prospective studies

Lukas Schwingshackl et al, Am J Clin Nutr 2017

21 prospective studies with 44,474 T2D cases

• The inverse association was observed only in Asian and

Australian studies, but not for American and European

studies.

• A significant inverse association was

observed between dairy consumption

and T2D (RR: 0.91; 95% CI 0.85–0.97).

• Each additional daily 200 g of dairy

products was inversely associated with

diabetes risk (RR: 0.97; 95% CI 0.94–0.99)


Turner KM, Keogh JB, Clifton PM. Dairy consumption and insulin sensitivity: a systematic review of short- and long-term intervention studies. Nutr Metab Cardiovasc Dis. 2015 Jan;25(1):3-8.

Conclusions (in adults):

• 4 Showed a positive effect on insulin sensitivity as assessed by HOMA.• 1 Showed a negative effect• 5 Showed No effect.

As the number of weight stable intervention studies is very limited and participant numbers small, these findings need to be confirmed by larger trials in order to conclusively determine any relationship between dairy intake and insulin sensitivity.


YOGURT AND HEALTH

In epidemiologic prospective studies usually

yogurt consumption

is inversely related to body weight gain, obesity,

metabolic syndrome, diabetes and cardiovascular

disease.

“ONLY YOGURT HAS BEEN ASSOCIATED TO A LOWER RISK OF DIABETES”

YOGURT AND DIABETES

17% lower risk of diabetes incidence in those consuming 3 or more servings of yogurt per week

41,436 men in the Health Professionals Follow-Up Study67,138 women in the Nurses' Health Study85,884 women in the Nurses' Health Study II

3,984,203 person-years of follow-up15,156 incident T2D cases

HRs for a serving yogurt consumption per day and type 2 diabetes

YOGURT AND DIABETES

The Australian Diabetes Obesity and Lifestyle Study

The Whitehall II Prospective Study

EPIC-Interact Study

Women’s Health Initiative

Japan Public Health Center–based Prospective Study

Women’s Health Study

Health Professional Follow-up Study

Nurses Health Study I

Nurses Health Study II

Per 1 serving

18% lower risk

Most of the studies were conducted in apparently healthy young or

middle-aged individuals from different populations.

No study has examined the association between dairy intake and risk

of diabetes in elderly individuals at high cardiovascular risk.

YOGURT AND DIABETES

HRs for type 2 diabetes according to tertiles of total, low-fat and whole-fat dairy

food consumption in the PREDIMED cohort

“Total and low-fat dairy

consumption was inversely

associated to a lower risk of

diabetes”

3.454 non-diabetic participants

270 incident cases of diabetes

(median follow-up of 4.1 years).

Díaz-López et al, Eur J Nutr 2015

DAIRY AND DIABETES

aTertile cut-offs are based on energy-adjusted cumulative average dairy food intake and values are medians

(interquartile range).

Cox regression models were used to assess the RR (95% CI) of diabetes according to tertiles of dairy food intake.

Model 1: Adjusted for age, sex and BMI.

Model 2: Additionally adjusted for dietary intervention group,

physical activity, educational level, smoking, hypertension,

dyslipidemia, and fasting glucose, HDL-cholesterol and

triglyceride levels.

Model 3: Additionally adjusted for cumulative average dietary

intakes in energy-adjusted quintiles (vegetables, legumes,

fruits, cereals, meat, fish, olive oil, nuts) and alcohol and

alcohol squared in g/day.

All models were stratified by recruitment center.

Total dairy, median (g/day): T1: 200; T2: 342; T3: 539Low-fat dairy, median (g/day): T1: 85; T2: 256; T3: 462Whole-fat dairy, median (g/day): T1: 0; T2: 20; T3: 97

HRs for type 2 diabetes according to tertiles of specific yogurt consumption in

the PREDIMED cohort

“Independently of the fat

content, a higher consumption

of yogurt has associated to a

lower risk of diabetes”





YOGURT AND DIABETES

aTertile cut-offs are based on energy-adjusted cumulative average dairy food intake and values are medians (Interquartil R).

Cox regression models were used to assess the RR (95% CI) of diabetes according to tertiles of dairy food intake.

Total yogurt, median (g/day):T1: 13; T2: 71; T3: 128 Low-fat yogurt, median (g/day): T1: 3; T2: 44; T3: 120 Whole-fat yogurt, median (g/day): T1: 0; T2: 7; T3: 45











HRs for type 2 diabetes according to tertiles of specific yogurt consumption in

the PREDIMED cohort

“Independently of the fat

content, a higher consumption

of yogurt has associated to a

lower risk of diabetes”





YOGURT AND DIABETES

aTertile cut-offs are based on energy-adjusted cumulative average dairy food intake and values are medians (interquartile

range). Cox regression models were used to assess the RR (95% CI) of diabetes according to tertiles of dairy food intake.

Total yogurt, median (g/day): T1: 13; T2: 71; T3: 128 Low-fat yogurt, median (g/day): T1: 3; T2: 44; T3: 120 Whole-fat yogurt, median (g/day): T1: 0; T2: 7; T3: 45

An average increment of one

serving/day of the standard serving of

yogurt (125 g) was associated with a

33% lower risk of T2D.











HRs (95% CI) for type 2 diabetes associated with the substitution of one serving of yogurt and low-fatmilk for one serving of other alternative foods in the PREDIMED cohort

Substituted foods Yogurt (125 g) Low-fat milk (200 mL)

Dairy desserts (100g)a 0.58 (0.29-1.18) 0.71 (0.35-1.41)

Biscuits and chocolate confectionary (50g) 0.60 (0.38-0.94) 0.69 (0.47-1.03)

Whole-grain biscuits and homemade pastries (50 g) 0.55 (0.32-0.96) 0.63 (0.38-1.05)

aPetit Suisse cheese or custard or ice cream. The servings are based on energy-adjusted cumulative average food intake. Values aregiven as HR (95% CI) from Cox regression models adjusted for age, sex, BMI, dietary intervention, physical activity, educational level,smoking, hypertension, or antihypertensive use (yes/no) and dyslipidemia (yes/no), and fasting glucose, HDL-cholesterol andtriglycerides levels. All models were stratified by recruitment center.

YOGURT SUBSTITUTION AND DIABETES


YOGURT AND DIABETES

0.90 0.95 1.05 1.10

Total dairy (n=17) (per 200g/d)

Low-fat dairy (n=13)(per 200g/d)

High-fat dairy (n=13)(per 200g/d)

Total milk (n=12)(per 200g/d)

Low-fat milk (n=7)(per 200g/d)

Cheese (n=13)(per 10g/d)

Number

publicationsHeterogenity test

I2 P-vaue

66.4 <0.001

High-fat milk (n=9)(per 200g/d)

68.0 <0.001

51.6 0.016

57.4 0.007

71.6 0.002

84.1 <0.001

61.7 0.002

Consumption of dairy foods and diabetes incidence: a dose-response meta-analysis of observationalstudies

Lieke Gijsbers et al, Am J Clin Nutr 2016

Yogurt (n=12)(per 10g/d)

61.7 0.002

RR

“This dose-response meta-analysis of observational studies suggest a posible role for dairy

foods, PARTICULARLY YOGURT in the prevention of T2D

Results should be considered in the context of the observed heterogeneity

YOGURT AND DIABETES

What are the mechanisms

explaining the beneficial

metabolic effects on

diabetes prevention of dairy

products and yogurt?

DAIRY, YOGURT AND DIABETES - mechanisms

First hypothesis:

The effect of dairy products and yogurt on diabetes

prevention may be explained by their beneficial effects on

satiety, reducing adiposity.

Effects related to the Ca2+ metabolism• An increase in intracellular Ca2+:

• Increases lipogenesis and inhibits lipolysis.

• Calcium present in dairy inhibits fatty acid absorption.

Effects related to the protein or bioactive peptides in dairy products• Inducing satiety.

The probiotic effects of yogurt• Inducing satiety and changing metabolic pathways implicated in lipogenesis and fat deposition.

“Los datos de los estudios observacionales, aunque no del todo consistentes,

indican un efecto protector del consumo de lácteos en general (incluyendo el

yogur) sobre el riesgo de sobrepeso y obesidad en adultos”

Relación entre el consumo lácteos y riesgo de sobrepeso y obesidad en adultos

EVIDENCIA DE ESTUDIOS PROSPECTIVOS

DAIRY AND OBESITY

120,877 U.S. women and men

Free of chronic diseases and not obese

at baseline.

Relationships between changes in food and

beverage consumption and weight changes

every 4 years, according to study cohort.

Mozaffarian et al, N Engl J Med 2011

YOGUR AND OBESITY

Cox Proportional Hazard Ratio (HR) and 95% confidence intervals (CI) of incident overweight/obesity according to

baseline frequency of total, whole-fat, and low-fat yogurt consumption.

Consumo de yogur y riesgo de incidencia de sobrepeso/obesidad:

ESTUDIO PROSPECTIVO sobre 8.516 participantes de la cohorte SUN (1999-2012).

“Una mayor frecuencia de consumo de yogur se asoció inversamente

con el desarrollo de sobrepeso/obesidad”

Martinez-Gonzalez et al, Nutr Metab Cardiovasc Dis. 2014

YOGUR Y OBESIDAD

YOGURT AND HEALTH

Second hypothesis:

The effect of dairy products and yogurt on diabetes

prevention may be explained by other mechanisms increasing

insulin sensitivity or decreasing pancreatic secretion.

Effects related to the Ca2+ metabolism• An increase in intracellular Ca2+ favors insulin secretion and glucose uptake.

Effects related to bioactive peptides in yogurt• Intestinal hormone activation inducing insulin secretion.• Whey protein consumed with a CH-meal increased insulin, and the incretin hormones glucagon-like peptide 1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP).

Beneficial effects of other components in yogurt• Minerals (phosphor, magnesium, potassium) and vitamins (A, D, B2, B6, B12) and dairy fat.

Effects related to the fat content

Ericson U. Am J Clin Nutr 2015

Total intake of high-fat dairy products was inversely associated with incident T2D (HR for highest compared with lowest quintiles: 0.77; CI 0.68-0.87; P-trend<0.001).

Most robust inverse associations were seen for intakes of high-fat fermented milk (P-trend<0.01) and for cheese in women (P-trend=0.02).

Intakes of saturated fatty acids with 4–10 carbons, lauric acid (12:0), and myristic acid (14:0) were associated with decreased risk (P-trend<0.01).

Conclusions: Decreased T2D risk at high intake of high- but not of low-fat dairy products suggests that dairy fat partly could have contributed to previously observed protective associations between dairy intake and T2D.


IS FAT FROM DAIRY UNHEALTHY AND INCREASES

THE RISK OF DIABETES?

Odd chain15:00

Pentadecanoic

Odd chain17:00

Heptadecanoic

Trans 16:1n-7Transpalmitoleic

Even chain14:00; 16:00

18:00

Swedish participants (Krachler 2008)

Erythrocyte membrane (-) (-) (+) palmitoleic

CHS (Mozzafarian 2010)

Circulating(-)

Insulin resistance

EPIC-Norfolk (Patel 2010)

Erythrocyte membrane, circulatingNS (-) NS (+) palmitoleic

EPIC-Postdam (Kröger 2011)

Erythrocyte membrane(-) (-)

NS myristic

NS palmitoleic

(+) stearic

MESA (Mozzafarian 2013)

Circulating(-)

Insulin resistance

EPIC-Interact (Farouhi 2014)

Circulating(-) (-) (+)

IRAS (Santoven 2014)

Circulating

(-)Insulin sensitivity

Β-cell function

NS

CHS: Cardiovascular Health Study; MESA: Multi-Ethnic Study of Atherosclerosis

IRAS: Triethnic Multicenter Insulin Resistance Atherosclerosis Study

Circulating or erythrocyte membrane fatty acid composition and diabetes incidence or glucose and insulin metabolism

Odd chain fatty acids

protect from diabetes


Widely distributed in many food

Endogenously

synthesized

Nurses' Health StudyHealth Professionals Follow-Up Study

Astrup A.

A changing view on saturated fatty acids and dairy: from enemy to friendAm J Clin Nutr. 2014;100(6):1407-8.

“The totality of evidence does not support that dairy SFAs increase the risk of coronary artery disease or stroke or CVD mortality”

“In contrast, lean dairy is clearly associated with decreased risk of T2D, and this effect is partly independent of any effect of body fat loss”

“There is no evidence left to support the existing public health advice to limit consumption of dairy to prevent CVD and T2D”


Substitutions between dairy product subgroups (per serving/d and risk of type 2 diabetes

Intake of whole-fat yogurt products in place of low-fat yogurt products, low-fat milk,

whole-fat milk and buttermilk are associated with a lower rate of type 2 diabetes

Low-fat yogurt products in place of whole-fat yogurtproducts was associated with a higher rate of type 2diabetes (HR 1·17; 95% CI 1·06, 1·29)

Whole-fat yogurt products in place of low-fat milk (HR0·89; 95% CI 0·83, 0·96), whole-fat milk (HR 0·89; 95% CI0·82, 0·96) or buttermilk (HR 0·89; 95% CI 0·81, 0·97) wereassociated with a lower rate of type 2 diabetes

n= 54 277 Danish Diet, Cancer and Health cohort

What makes the yogurt different?

Is a marker of a healthy lifestyle?

Replace other unhealthy or healthy

foods when consumed?

Possible probiotic effects: changing

gut microbiota and body metabolism

• New active metabolites decreasing insulin resistance.

• Insulin secretion induced by menaquinones (Vit K2) synthetized by the gut microbiota.

YOGURT AND HEALTH

In epidemiologic prospective studies usually yogurt consumption is

inversely related to body weight gain, obesity, metabolic syndrome,

diabetes and cardiovascular disease.

CVDCAD Stroke Hypertension

Total dairy Neutral Neutral Favorable

Moderate High Moderate

Regular- orhigh-fat dairy

Uncertain Neutral Neutral

Very low High Moderate

Low-fat dairy Uncertain Neutral Favorable

Very low High Moderate

Milk Uncertain Neutral Neutral

Very low Moderate Moderate

Cheese Neutral Neutral Favorable

High Moderate Moderate

Yogurt Neutral Neutral Neutral

Moderate Moderate Moderate

Fermented dairy Uncertain Uncertain Favorable

Very low Very low Moderate

YOGUR AND CARDIOVASCULAR DISEASE

Systematic Review of the Association between Dairy Product Consumption and

Risk of Cardiovascular-Related Clinical Outcomes Drouin-Chartier et al., 2016

CARDIOVASCULAR DISEASE

Classical Risk Factors Novel Risk Factors

Major Unmet Clinical Need

Metabolic syndrome

Abdominal

Obesity

HDL-C

TG

TNF IL-6

PAI-1

Glu

Insulin

T2DM

Smoking LDL-C BP

YOGUR AND METABOLIC SYNDROME

Prevalence of Metabolic Syndrome in Catalonia, Spain in 1992-1993 and 2002-2003 using two different definitions

0

10

20

30

40

50

60

18-24 25-34 35-44 45-54 55-64 65-74 Total

Grupo de edad (años)

Pre

va

len

cia

de

SM

et

(%)

SMet 1992 ATPIII

SMet 2002 ATPIII

Muestra representativa de

la población de Catalunya

Buckland et al, Nutrition Reviews, 2009

YOGUR Y SÍNDROME METABÓLICO

Prevalencia de Síndrome Metabólico

Dairy consumption and the incidence of MetS: PROSPECTIVE STUDIES

“Higher total dairy consumption

(including yogurt and chesses)

was associated with lower

incidence MetS”

YOGURT AND METABOLIC SYNDROME

Pérez-Martínez et al, 2017

Evidence: There is no evidence to support the existing public health advice to limit consumption of dairy products to prevent MetSRecommendation: Dairy products and particularly yogurt consumption may be useful in preventing MetS

Cox regression models adjusted for intervention group, sex, age, physical activity and BMI and baseline current smoker, and hypoglycemic, hypolipidemic,

antihypertensive and insulin treatment, cumulative average consumption of vegetables, fruit, legumes, cereals, fish, red meat, alcohol, biscuits, olive oil and nuts.

Independent of the fat content,

Yogurt consumption was

inversely associated with the

incidence of MetS and its

components

Yogurt consumption and incidence of MetS or its components: PREDIMED study

1.868 participants without MetS at

baseline; 930 incident cases of

MetS (mean follow-up: 3.2 y)

P for trend=0.230

P for trend=0.004

P for trend=0.689

P for trend=0.348

P for trend=0.183

P for trend=0.048

P for trend=0.005

P for trend=0.001

P for trend<0.001

P for trend<0.001

P for trend=0.095

P for trend=0.126

P for trend=0.864

P for trend=0.011

P for trend=0.001

Central obesity

High fasting plasma glucose

High blood pressure

Low HDL-c

High triglicerides

Metabolic Syndrome P for trend=0.144

TOTAL YOGURT

Central obesity


High blood pressure

Low HDL-c

High triglicerides


WHOLE-FAT YOGURT

Central obesity


High blood pressure

Low HDL-c

High triglicerides


LOW-FAT YOGURT

0.5 1.0 2.0

HAZARD RATIO (95% CI)

Hazard ratios (95% CI) of metabolic syndrome and its components across energy-

adjusted tertiles of yogurt consumption (Tertile 3 vs Tertile 1).

↓23%

↓22%

↓27%

“Low-fat dairy products were inversely associated with MetS incidence”

“The consumption of cheese was associated with an increased risk of MetS incidence”

YOGURT AND METABOLIC SYNDROME

Babio et al, 2015

TOTAL DAIRY AND METS

There was an inverse association between total dairy intake and incidence of MetS (RR= 0.73, 95%CI= 0.64–0,83).

Dairy products consumption in the prevention of metabolic syndrome: a systematic review and

meta-analysis of prospective cohort studies.

Mena-Sánchez G et al, 2018 (Working paper –under review- )

MILK AND METS

An inverse association was observed between total milk intake and incidence of MetS (RR= 0.79, 95%CI= 0.64–0,97).




YOGURT AND METS

There was an inverse association between total yogurt intake and incidence of MetS (RR= 0.74, 95%CI= 0.66–0,82).




YOGURT AND METS

The pooled risk showed a linear association between one serving of total yogurt consumption/day and the risk of MetS [0.77 (95% CI, 0.60–1.00); P = 0.046]



Mena-Sánchez G et al, XXXX 2018 (Working paper –under review- )

Three studies were included in the dose–response analysis of

total yogurt consumption and the

risk of MetS.

CONCLUSIONS

▪ A high intake of total dairy products was associated with decreased risk of Obesity, Hypertension, T2D and MetS in several prospective studies (in children and adults).

▪ A high intake of low-fat dairy products was associated with decreased risk of T2D, HT and MetS, but not with body weight.

▪ Total milk was associated with decreased risk of Obesity and MetS in cross-sectional and prospective studies but not with HT.

▪ Frequent yogurt consumption was consistently associated to a lower risk of obesity, diabetes and MetS and this association was independent of the fat content.

▪ Substitutions of one serving of yogurt per day for one serving of other “unhealthy” snacks or food alternatives per day was associated with a reduced risk of T2D incidence.

CONCLUSIONS

▪ Any type of dairy product was associated to an increased risk of Obesity, T2D, Hypertension or MetS.

▪ In general, full-fat dairy products do not have demonstrated deleterious effects on Obesity, T2D, Hypetension or MetS.

▪ Several mechanisms have been suggested in order to explain these associations, however more mechanistic studies are needed.

▪ Large clinical trials with an appropriate design are warranted to definitively demonstrate that yogurt consumption protects from diabetes.

▪ Consumers can continue to moderately consume full-fat dairy products as part of a healthy and balanced lifestyle, however yogurt products would be preferential for potential cardiovascular health benefits.

Hospital Universitario de Sant Joan de Reus

Universitat Rovira i Virgili

Unidad de Nutrición Humana

Investigadores estudio PREDIMED

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