Effect of 1-Year Dairy Product Intervention on Fat Mass in Young Women : 6-Month Follow-up

Effect of 1-Year Dairy Product Intervention
on Fat Mass in Young Women: 6-Month
Follow-up
Marianne S. Eagan,* Roseann M. Lyle,† Carolyn W. Gunther,‡ Munro Peacock,§ and Dorothy Teegarden‡
Abstract
at each time-point (baseline, r ? ?0.41, p ? 0.003; 12
EAGAN,
MARIANNE
S.,
ROSEANN
M.
LYLE,
months, r ? ?0.42, p ? 0.002; 18 months, r ? ?0.32, p ?
CAROLYN W. GUNTHER, MUNRO PEACOCK, AND
0.02) but did not predict changes in fat mass.
DOROTHY TEEGARDEN. Effect of 1-year dairy product
Discussion: Dietary calcium intake over 18 months pre-
intervention on fat mass in young women: 6-month follow-
dicted a negative change in body fat mass. Thus, increased
up. Obesity. 2006;14:2242–2248.
dietary calcium intakes through dairy products may prevent
Objective: Previous results from this laboratory suggest that
fat mass accumulation in young, healthy, normal-weight
a 1-year dairy intake intervention in young women does not
women.
alter fat mass. The objective of this study was to determine
the impact of the 1-year dairy intervention 6 months after
Key words: calcium, women, intervention, body compo-
completion of the intervention.
sition, fat mass
Research Methods and Procedures: Previously, normal-
weight young women (n ? 154) were randomized to one of
three calcium intake groups: control (?800 mg/d), medium
Introduction
dairy (1000 to 1100 mg/d), or high dairy (1300 to 1400
Obesity is a rapidly growing epidemic world wide. Re-
mg/d) for a 1-year trial (n ? 135 completed). In the current
cent estimates suggest that 30% of adults age 20 years or
study, 51 women were assessed 6 months after completion
older are obese (1). In 2003, more than 25% of the adult
of the intervention trial. Body compositions (body fat, lean
population in four states were obese (1). Furthermore, 16%
mass) were measured using DXA. Self-report question-
of the children and teens in the U.S. were overweight, and
naires were utilized to measure activity and dietary intake
this percentage has tripled since 1980 (1). Although genetics
(kilocalories, calcium).
play an important role, the rapid rise in the development of
Results: The high-dairy group (n ? 19) maintained an
obesity supports that lifestyle factors are likely to contribute
elevated calcium intake (1027 ? 380 mg/d) at 18 months
substantially to this condition (1).
compared with the control group (n ? 18, 818 ? 292; p ?
Results from epidemiological research suggest that cal-
0.02). Mean calcium intake over the 18 months predicted a
cium from dairy products is negatively associated with body
negative change in fat mass (p ? 0.04) when baseline BMI
weight (2– 4). However, results of intervention trials have
was controlled in regression analysis (model R2 ? 0.11).
been variable. Increased dairy product intake incorporated
25-Hydroxyvitamin D levels were correlated with fat mass
into weight loss diets leads to decreased fat mass and waist
circumference in several randomized intervention trials
(6,7). The results of weight loss trials that include calcium
supplementation are more variable (7,9). Little information
Received for review November 16, 2005.
Accepted in final form August 31, 2006.
is available on the effects of dairy products or calcium
The costs of publication of this article were defrayed, in part, by the payment of page
intake on prevention of fat mass or weight gain. A 2-year
charges. This article must, therefore, be hereby marked “advertisement” in accordance with
18 U.S.C. Section 1734 solely to indicate this fact.
prospective trial (n ? 54) showed that calcium intakes,
Departments of *Foods and Nutrition and †Health and Kinesiology, and ‡Interdepartmental
when corrected for energy intakes, were negatively associ-
Nutrition Program, Purdue University, West Lafayette, Indiana and §Department of Medi-
ated with the 2-year change in weight and fat mass (9). Of
cine, Indiana University, Indianapolis, Indiana.
Address correspondence to Dorothy Teegarden, Interdepartmental Nutrition Program, Pur-
the 17 calcium supplementation intervention studies re-
due University, 1264 Stone Hall, 700 West State Street, West Lafayette, IN 47907.
viewed by Barr (10), only one showed less weight gain in
E-mail: dteegard@purdue.edu
Copyright © 2006 NAASO
the calcium-supplemented group compared with the con-
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Dairy Products and Fat Mass: Follow-up Study, Eagan et al.
trols (11,12). Therefore, the impact of calcium or dairy
cium intake and changes in body composition 6 months
products on body fat remains controversial.
after the completion of the original study.
There are several proposed mechanisms for the negative
impact of dietary calcium on body weight regulation. There
are data to suggest that high concentrations of calcium
Research Methods and Procedures
intake can decrease absorption of dietary fatty acids through
Subjects
the formation of indigestible calcium soaps in the gastroin-
The current study employed the participants who were
testinal tract (13,14). Dietary calcium regulation of parathy-
willing to return for assessment 6 months after their com-
roid hormone (PTH)1 and 1,25 dihydroxyvitamin D
pletion of a 1-year randomized dairy product intervention
3
[1,25(OH) D ] has also been proposed to mediate the ef-
whose primary endpoints were body composition and
2
3
fects of calcium on fat mass. Higher intakes of calcium
weight [n ? 154; mean age, 20.1 years (?2.4)]. The parent
suppress PTH and subsequently 1,25(OH) D. Both PTH
study is described in detail elsewhere (18). In brief, inclu-
2
and 1,25 dihydroxyvitamin D increase levels of intracellu-
sion criteria included calcium intakes ?800 mg/d and en-
3
lar calcium in adipocytes, which can lead to a decrease in
ergy intakes ?2200 kcal/d. Exclusion criteria included
lipolysis and an increase in lipogenesis through increases in
?20% overweight or 15% underweight according to the
fatty acid synthase levels in the cell (15). This shift in lipid
Metropolitan Life Insurance Tables (19). Letters were sent,
use may lead to an accumulation of fat. In addition, 25-
1 month before the 18-month time-point, to all subjects who
hydroxyvitamin D (25OHD), the marker for vitamin D
had completed the 1-year trial inviting them to participate in
status, is negatively associated with serum PTH (16,17).
the 6-month follow-up study. Seventy-one subjects ex-
Thus, vitamin D status may be associated with fat mass
pressed interest in the follow-up assessment, and 51 com-
through regulation of PTH as well.
pleted all analysis and questionnaires. There was no other
Gunther et al. (18) reported results from a 1-year dairy
contact between the investigators and the participants be-
product intervention trial in healthy, normal-weight young
tween the end of the 1-year trial and the 6-month follow-up.
women. In this trial, women with low calcium intakes were
The Purdue University Institutional Review Boards ap-
randomized to one of three calcium intake groups: control
proved both studies, and participants provided written, in-
(?800 mg/d), medium dairy (1000 to 1100 mg/d), or high
formed consent.
dairy (1300 to 1400 mg/d), where dairy products were
substituted for other diet components to maintain an isoca-
Anthropometric and Body Composition Measurements
loric diet. There was no effect on body fat mass or weight
Measurements were taken at baseline, 12, and 18 months
during increased dairy product intake in the 1-year inter-
between Days 3 and 11 of the menstrual cycle (follicular
vention trial. However, it is likely that an effect related to
phase) and between 7 AM and 11 AM after a 12-hour fast.
prevention of increases in fat mass may be small, albeit
Height of each subject, to the nearest one-tenth of a centi-
significant, over a period of time (3,4). For example, the
meter, was measured using a stadiometer (Holtain Limited,
difference between the placebo control and the calcium-
Crymych, Dyfed, United Kingdom). Weight, to the nearest
supplemented groups in the study of Davies et al. (12) was
0.5 pound (1.1 kg), was measured using a standard physi-
0.346 kg/yr. This demonstrates a small but significant ef-
cian’s balance beam scale (Healthometer, Inc., Bridgeview,
fect; thus, the length of this trial (?4 years) may have
IL). These measures were taken with the subject wearing
indoor clothes but without shoes. Total body fat mass and
enhanced the ability to measure these small changes. Trials
lean mass were measured with DXA (software version 4.3e;
of shorter duration, small sample sizes, and/or lack of con-
Lunar Corp., Madison, WI). Body weight and body com-
trol for individual energy intake may not yield sufficient
position measures are expressed as change at 18 months
power to detect small changes in body fat that dietary
from baseline (18 months ? baseline).
calcium may elicit.
Therefore, the current study examined the cohort used in
the study by Gunther et al. (18) at 6 months after the
Assessment of Dietary Intake and Other Lifestyle
completion of the 1-year dairy product intervention trial.
Factors
A food frequency questionnaire (20) was administered to
The current study tested whether differences in fat mass
screen participants for eligibility based on daily calcium and
may be detectable when higher calcium intakes are main-
energy (kilocalories) intakes. Dietary intake of calcium
tained for a longer period of time. The purpose of the
from all sources was assessed by 3-day food records at
current study was to determine whether participation in a
baseline, 12, and 18 months. Dietary records were reviewed
1-year dairy calcium intervention results in changes in cal-
and analyzed by one trained nutritionist employing the
Nutrition Data System for Research, version 4.04, Food and
1
Nutrient Database 28 (Minneapolis, MN). Dietary calcium
Nonstandard abbreviations: PTH, parathyroid hormone; 25OHD, 25-hydroxyvitamin D;
GLM, general linear model.
intake, which includes dairy calcium intake and supple-
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Dairy Products and Fat Mass: Follow-up Study, Eagan et al.
ments, is utilized in the analysis. Lifestyle questionnaires
Statistical Analysis
assessed previous and current medical history and medica-
All data are reported as means ? SD. Data were analyzed
tion use at baseline, 12, and 18 months.
using Statistical Analysis System (version 8.2; SAS Insti-
tute, Inc., Cary, NC). Univariate analysis was completed on
variables. ANOVA, Pearson correlation, and general linear
Laboratory Methods
model (GLM) were used as described in the results. Depen-
Blood samples were collected at baseline, 12, and 18
dent variables include absolute values and changes in fat
months between Days 3 and 11 of the menstrual cycle
mass, lean mass, weight, and BMI. Predictive variables
(follicular phase) after a 12-hour fast. After collection,
include dietary group assignment, calcium intake, and
blood samples were immediately centrifuged and serum
change in calcium intake. Covariates were absolute values
stored at ?80 °C. Serum samples were analyzed for levels
and changes in BMI, energy intake, and 25OHD. p ? 0.05
of 25OHD with enzyme-linked immunosorbent assay (Dia-
was considered significant.
Sorin, Inc., Stillwater, MN).
Results
Dairy Product Intervention Protocol
Of the 154 participants who were enrolled in the parent
After completion of baseline testing, participants were
study, 135 completed the 12-month intervention, and 51
randomized into one of three groups: a control group (main-
participants returned at 6 months after completion of the
tain current dietary consumption), a medium-dairy group
intervention (18 months). The participants who did not
(1000 to 1100 mg calcium/d from dairy), and a high-dairy
complete the 18-month follow-up (n ? 83) were older
group (1300 to 1400 mg/d calcium/d from dairy). Random-
(20.6 ? 2.6 years) at baseline compared with the partici-
ization was stratified by oral contraceptive use and energy
pants who completed the follow-up (n ? 51, 19.4 ? 1.6
intake, such that equal numbers of women in each energy
years, p ? 0.001). There were no other differences between
decile (1200 to 1299, 1300 to 1399, 1400 to 1499, etc.)
the completers and non-completers. There were no signifi-
would be in each treatment group.
cant differences in baseline characteristics (0 months) by
Participants randomized into the dairy calcium groups
intervention dietary group assignment of the 51 subjects
received individual dietary counseling by trained nutrition-
who completed the 18-month follow-up (Table 1). There
ists and were instructed to increase daily calcium intakes by
were also no significant differences in age, weight, fat mass,
substituting dairy products rich in calcium, with an empha-
lean mass, or energy intake at 18 months by intervention
sis on non- and low-fat milk. To maintain isocaloric intakes,
dietary group assignment (Table 1).
participants were instructed to remove other dietary com-
The impact of higher dairy product intervention for 12
ponents to approximately equal the added dairy intake cal-
months on 18-month dietary calcium intakes was assessed.
ories. A record of daily dairy intake and foods removed
There was a trend toward group assignment predicting
from the diet to maintain an isocaloric diet were returned
18-month calcium intake (r ? 0.07; p ? 0.06) in ANOVA.
monthly by participants in the intervention groups to assess
In these analyses, 18-month calcium intake of the high-dairy
compliance. The logs were checked for accuracy by a nu-
product intake intervention group was greater than the con-
tritionist; if errors were found in the log, the participant was
trol (1028 ? 380 vs. 818 ? 293, respectively; p ? 0.04) and
contacted and retrained to follow the dietary protocol. Di-
trending to being greater than the medium-dairy intake
etary counseling was provided throughout the duration of
intervention group (799 ? 308; p ? 0.06) (Table 1). Fur-
the study. Subjects randomized into the control group were
thermore, the high-dairy group, but not the control or me-
instructed to make no changes to their dietary patterns for
dium-dairy groups, increased calcium intake from baseline
12 months after randomization.
(Table 2). When corrected for 18-month calorie intake in a
GLM, intervention group assignment predicted 18-month
Activity
calcium intake (p ? 0.03), indicating that the high-dairy
Three-day physical activity records (21) were collected
intake group maintained a higher calcium intake. Thus,
from all subjects at baseline and 3-month intervals through-
high-dairy product intake during 1-year intervention trial
out the 1-year intervention study and again at 18 months to
increased 18-month calcium intakes.
assess energy expenditure (kilocalories per day). Briefly,
The impact of the higher dairy product intake interven-
participants were counseled to record activity in 15-minute
tion on 18-month body composition measures was assessed.
time periods throughout the day using an activity code
Similar to the results of the participants who completed the
defined by nine categories. The categories range from 1,
12-month dairy product intervention trial, group assignment
lying down (0.26 kcal/kg per 15 minutes) to 9, intense
did not predict the 12-month change from baseline in fat
work/activity (1.95 kcal/kg per 15 minutes). An estimate of
mass in the participants who completed the 18-month fol-
24-hour energy expenditure was calculated based on the
low-up study (n ? 51). In addition, group assignment did
results.
not predict change in 18-month fat mass or weight from
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Dairy Products and Fat Mass: Follow-up Study, Eagan et al.
Table 1.
Baseline and 18-month characteristics of subjects (mean ? standard deviation)*
Control n ? 18
Medium dairy n ? 14
High dairy n ? 19
Parameter
Baseline
18 Months
Baseline
18 Months
Baseline
18 Months
Age (y)
19.6 ? 1.7
21.2 ? 1.8
19.1 ? 0.9
20.9 ? 0.83
19.5 ? 2.0
20.9 ? 1.9
Weight (kg)
60.8 ? 11.6
61.2 ? 10.9
66.1 ? 13.7
66.3 ? 14.8
61.2 ? 7.6
61.5 ? 7.4
BMI (kg/m2)
21.9 ? 3.4
22.0 ? 3.0
23.4 ? 4.7
23.6 ? 5.1
21.9 ? 2.6
22.1 ? 2.5
Fat mass (kg)
17.0 ? 8.3
16.6 ? 7.2
21.3 ? 10.4
21.1 ? 11.8
17.4 ? 5.6
17.0 ? 5.4
Lean mass (kg)
40.1 ? 4.7
40.9 ? 5.0
40.1 ? 3.4
41.0 ? 3.4
39.8 ? 4.5
40.6 ? 3.7
Calcium intake
(mg/d)
765 ? 248
818 ? 293
721 ? 265
799 ? 308
686 ? 239
1028 ? 380*
Energy intake
(kcal/d)
1786 ? 523
1732 ? 343
1670 ? 507
1605 ? 519
1838 ? 377
1699 ? 473
25OHD (ng/mL)
24.1 ? 7.2
23.8 ? 7.2
23.2 ? 8.0
21.5 ? 8.9
25.9 ? 11.4
24.9 ? 9.0
* Signficantly different from Control 18 months (p ? 0.04), and a trend towards a difference from Medium 18 months (p ? 0.06).
baseline in a GLM, even when controlled for baseline BMI.
intake ? ?0.0027) ? (baseline BMI ? ?0.146)
There was a trend for 18-month dietary calcium intake to
correlate with change in fat mass when uncontrolled (r ?
None of the dietary variables (group assignment nor
?0.25; p ? 0.08), and even when controlled for baseline
calcium intakes) was correlated with changes in lean mass,
BMI (r ? ?0.27, p ? 0.06). This trend became significant
whether or not analyses were controlled for baseline BMI.
(r ? ?0.28; p ? 0.05) when analyses were controlled for
Thus, the mean dietary calcium intake over 18 months was
group in addition to baseline BMI. Inclusion of physical
associated with reduced fat mass.
activity or mean caloric intake in the model did not alter the
To further explore the relationship between calcium in-
results. Consistent with this, the mean calcium intake for the
take over 18 months and fat mass accumulation, the cohort
intervention and follow-up combined (mean of 6-, 12-, and
was subdivided by mean calcium intake of either greater
18-month dietary records) (p ? 0.04) predicted the 18-
than or less than 800 mg/d. The mean fat mass of each of
month change in fat mass when controlled for baseline BMI
these subgroups over the time of the intervention and the
in a regression model (R2 ? 0.11):
18-month follow up are shown in Figure 1. Fat mass was
significantly different between these subgroups at 18
18-Month change in fat mass ? 5.869 ? (mean calcium
months (p ? 0.02).
Table 2.
Change in characteristics of subjects from baseline to 18 months (mean ? standard deviation).
Control
Medium dairy
High dairy
Change parameter
(n ? 18)
(n ? 14)
(n ? 19)
Weight (kg)
0.4 ? 1.7
0.1 ? 6.7
0.3 ? 3.0
BMI (kg/m2)
0.1 ? 0.6
0.1 ? 1.3
0.2 ? 1.3
Fat mass (kg)
?0.39 ? 1.99
?0.32 ? 4.94
?0.43 ? 2.8
Lean mass (kg)
0.85 ? 1.3
0.80 ? 1.3
0.81 ? 1.3
Calcium intake (mg/d)*
53 ? 349
78 ? 407
341 ? 415†
Energy intake (kcal/d)
?53 ? 646
135 ? 521
?139 ? 407
* p ? 0.06 main effect of group assessed by ANOVA.
† p ? 0.002 Paired t test difference from zero.
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Dairy Products and Fat Mass: Follow-up Study, Eagan et al.
fore, increasing dairy product intake in either children or
adults for a period of time may lead to enhanced subsequent
calcium intakes. The results of this study suggest that par-
ticipating in an intervention may affect a change in dietary
habits for up to 6 months.
Although the perception exists that dairy products will
lead to increased weight, in fact, dairy product intake may
prevent fat mass gain. In the original cohort (18), the control
and low dairy groups did not gain weight over the year;
thus, the prevention of weight gain hypothesis was not
tested. Our results demonstrate that consuming higher dairy
intakes over the 1-year trial promoted increased calcium
intakes up to 6 additional months, although not all partici-
pants continued to consume higher levels of calcium. In our
models, to predict changes in fat mass required high calcium
intakes for the year of intervention (group assignment) and
Figure 1: Fat mass (kg) from baseline to 18 months by subgroups
continued high calcium intake for another 6 months (18-
of ? or ?800 mg/d calcium intake. (*) p ? 0.02 between groups
month calcium intake). Thus, if one consumes higher cal-
at 18 months.
cium intakes for 1 year, and then reduces the intake, it may
not have a measurable effect on fat mass. However, if one
maintains the higher calcium intake for a longer period of
The relationship between serum levels of 25OHD and
time, in this case 18 months, the differences in fat mass
changes in fat mass, weight, and BMI were explored. When
become measurable. The current study suggests that women
25OHD was added to models to predict changes in body
on low calcium intakes will gain fat mass, and higher
composition, the results were similar to those reported
calcium intakes will reduce fat mass accumulation progres-
above. Changes in 25OHD at any time-point did not predict
sively over 18 months (Figure 1), leading to a small but
changes in any body composition measure. However,
significant difference in total fat mass between these two
25OHD levels were correlated with fat mass at each time-
populations.
point (baseline, r ? ?0.41, p ? 0.003; 12 months, r ?
To determine the biological impact, the regression equa-
?0.42, p ? 0.002; 18 months, r ? ?0.32, p ? 0.02).
tion described in the results section, which predicted the
18-month fat mass change by mean dietary calcium intake
over 18 months when controlled by baseline BMI, was
Discussion
applied. Substituting various calcium intakes into Equation
The results of the current study indicate that increasing
1 yields, for 500 mg/d, a fat mass gain of 1.26 kg over 18
dairy product intake through an intervention study promotes
months, and for 1200 mg/d, a fat mass loss of 0.631 kg over
increased calcium intakes 6 months after the end of the
18 months. The difference in fat mass accumulation is
study period. Furthermore, increased calcium intake leads to
?1.89 kg between these two dietary calcium intake expo-
a decreased fat mass compared with a low calcium intake
sures over 18 months in normal-weight young women.
over 18 months. There was no effect of group assignment on
Although this is a small change, if this effect is maintained
body fat mass or weight in this cohort (n ? 51) at 12
over time, it will have a significant impact on the develop-
months, which is similar to the total 135 who completed the
ment of obesity. These changes are slightly higher than
12-month study. Thus, the results of the current study sup-
those of Davies et al. (12), who showed a 0.346 kg/yr
port that the impact of calcium intake may be sufficiently
difference in weight change between placebo and calcium
small or that fat mass is influenced by other factors, such
supplemented (1200 mg/d supplement) in an ?4-year ran-
that it is difficult to detect an effect at 12 months in a
domized control trial with post-menopausal women. Al-
normal-weight, healthy young female sample.
though this is a different age group than the current cohort,
The results of this study demonstrate that higher calcium
the estimated size effect is strikingly similar between the
intakes were maintained once the dietary habit was estab-
two studies. Using the results from specific cohorts from
lished in a year-long intervention. This is similar to the
observational studies, Heaney (24) estimated the potential
concept that higher dairy product intake as a child is asso-
impact of doubling dietary calcium intake in these cohorts.
ciated with higher calcium intakes as an adult (22). It is
The results suggest that, over time, doubling the dietary
important to develop strategies to promote increased cal-
calcium intakes of these cohorts predicts a substantial
cium intakes in the U.S. population because intakes are
change in overweight and obese prevalence by as much as
generally far below current recommendations (23). There-
60% to 80% (24).
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Dairy Products and Fat Mass: Follow-up Study, Eagan et al.
In this study, the influence of calcium on fat mass cannot
understand the influence of calcium and/or dairy products
be separated from other dairy product components because
on prevention of fat mass gain.
the increase in dietary calcium was achieved through dairy
product intake. A few studies (5,8,12,13), but not all (7,11),
Acknowledgment
suggest an independent effect of calcium; however, longer
This work was supported by Dairy Management, Inc.
studies may be necessary to detect differences (3,4,11).
(Rosemont, IL).
There is some evidence to support the role of other dairy
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