Medicina (Buenos Aires)
versión On-line ISSN 1669-9106
Medicina (B. Aires) v.66 n.6 Buenos Aires nov./dic. 2006
Association between dietary habits, education, serum triglycerides and blood cholesterol among women of Cabildo, Buenos Aires
Raúl J. Schneider1, Noel Barengo2, Irja Haapala3, Marcelo Tavella4
1 Facultad de Ciencias de la Salud, Universidad Adventista del Plata, Libertador San Martín, Entre Ríos;
2 Department of Public Health and General Practice, University of Kuopio, Kuopio, Finland;
3 Department of Nutrition and Dietectics, King's College, London, England;
4 Programa de Infarto en Argentina, Instituto de Investigaciones Bioquímicas de La Plata (UNLP-CONICET)
Postal address: Dr. Raúl J. Schneider, Belgrano 190, 3103 Libertador S. Martín, Entre Ríos, Argentina; Fax: (54-0343) 4910-348
A cross sectional study of 107 women between 20 and 69 years old, living in the town of Cabildo, province of Buenos Aires, Argentina, which describes food intake and analyses its relation to their education, blood cholesterol and serum triglyceride levels. A food frequency questionnaire including questions regarding meal patterns and food use were completed by the participants. Questions regarding educational status were included. A nutritional risk score was created from nine food groups. Total blood cholesterol and serum triglyceride levels were determined. Average total blood cholesterol levels of the women who participated in the present study were higher (209 mg/dl) than those recommended by the National Cholesterol Education Program, while triglyceride values remained within the normal range (124 mg/dl). Total blood cholesterol levels increased with age. Bread, biscuits and cakes were consumed on a daily basis by 98% of the participants and dairy products by 92%, these being mainly full-fat. Meat and fast food intake were very high (96% and 100% respectively). Vegetable and fish intakes were higher among the more educated women. Mayonnaise (58%) and butter (43%) are popular as food dressings and bread spreads respectively, and sunflower oil was the most commonly used for cooking by 94% of the participants. Women with low educational levels (less than 7 years) had higher nutritional risk scores, and thus unhealthier dietary habits than those with more years of formal education. No statistically significant association was found between food groups and cholesterol or triglyceride levels.
Key words: Cholesterol; Triglycerides; Nutrition; Food use; Argentina
Asociación entre hábitos nutricionales, educación, triglicéridos séricos y colesterol total en mujeres de Cabildo, Buenos Aires.Se realizó un estudio transversal en 107 mujeres, habitantes del pueblo de Cabildo, provincia de Buenos Aires, Argentina, sobre el consumo de alimentos entre mujeres de 20 a 69 años de edad, analizando su relación con la educación, colesterol total y niveles de triglicéridos. Se encuestó a las participantes sobre el tipo y frecuencia de consumo alimentario y el nivel de educación. Se creó un puntaje de riesgo nutricional a partir de nueve grupos de alimentos. Se midieron los niveles de colesterol total y triglicéridos de las participantes. El nivel promedio de colesterol total de las mujeres participantes fue superior (209 mg/dl) al normal según el recomendado por el National Cholesterol Education Program, mientras que el nivel promedio de triglicéridos se mantuvo dentro del rango normal (124 mg/dl). Los niveles de colesterol total aumentaban con la edad. El 98% consumía pan y galletitas regularmente y el 92% productos lácteos, de estos últimos la mayoría eran enteros. El consumo de carnes (96%) y comidas rápidas (100%) era muy alto. Las participantes con más años de educación consumían más pescado y vegetales. Mayonesa (58%) y manteca (43%) eran habitualmente utilizadas para acompañar comidas y untar pan. El aceite de girasol era el más utilizado para cocinar (94%). Las mujeres con menos años de educación (< 7 años) presentaban un puntaje de riesgo nutricional más elevado, y por ende hábitos nutricionales menos sanos. No se encontró una relación estadísticamente significativa entre los grupos de alimentos y niveles de colesterol total y triglicéridos.
Palabras claves: Colesterol; Triglicéridos; Nutrición; Alimentos; Argentina
Most saturated fats are risk factors of cardiovascular diseases and increase total serum cholesterol as well as low density lipoprotein cholesterol. Whereas polyunsaturated fatty acids seem to lower serum cholesterol concentrations1, the scientific evidence regarding a cholesterol lowering effect of monounsaturated fats is scant2, 28, 29. Dietary cholesterol increases serum cholesterol1-6, 28, 29. The American Heart Associations recently revised dietary guidelines limiting the consumption of saturated fat to <10% of energy and cholesterol <300 mg/day to reduce the risk of cardiovascular heart disease3.
The Seven Countries Study4 found a positive association between the percentage of total energy intake from saturated fatty acids and serum cholesterol. A high saturated fat and cholesterol diet increases the risk of coronary heart disease due to their adverse metabolic effects on blood cholesterol concentration5. The high consumption of saturated fatty acids and cholesterol is mainly responsible for hypercholesterolemia6-11, 30-32. A reduction in the consumption of saturated fatty acids found in butter, margarines and some types of oils, for instance, decreases total blood cholesterol and triglycerides levels significantly7-11.
Argentina has the fourth highest rate of cardiovascular mortality in the Americas12. It has been shown that one of the main risk factors for atherosclerotic vascular diseases in Argentina is excess consumption of saturated fats13, 15, 17. However, little is known about the impact nutritional habits have on triglyceride and cholesterol levels in the average Argentinean population. Traditionally, the main components of the usual Argentinean diet have been beef, whole fat dairy products and other high lipid containing products14.
Coniglio15 compared two population groups, and concluded that those that had a diet rich in monounsaturated and polyunsaturated fatty acids, and low in saturated fatty acids had lower cholesterol levels. In 1999, Parada and Cozza16showed an inverse association between the consumption of meat, butter, milk and other dairy products with increments in fibre rich products, oil, low fat meat cuts and skim milk and cholesterol levels, during a 13 year follow-up study in Argentina. A steady decrease in cholesterol levels was recorded, due to changes in nutritional habits. Despite nutritional changes over the last years, cardiovascular diseases are still the number one cause of death in Argentina12, 13, 15, 17.
Little information is available on the cholesterol and triglyceride levels of the Argentinean population15, 16. Furthermore, hardly any of the previous investigations that have taken place in Argentina have focused on the relationship between individual food groups, general dietary habits and cholesterol and triglyceride levels.
The aim of the present study was to describe food use in a representative sample of women living in the town of Cabildo, and to analyse these in relation to total blood cholesterol and triglyceride levels, and the influence that education has over dietary tendencies.
Materials and Methods
A cross sectional population survey was carried out among 20-69 years-old women in Cabildo, Argentina, in 2001. Cabildo is a small town located in mid-eastern Argentina, in the province of Buenos Aires. Interviews with standardized and structured questionnaires were conducted by seven trained members of the research team, each assigned to different parts of town. Prior to the at-home-visits, radio and TV announcements were made to inform the citizens about the survey and to ask for the female members of the household to be present on the weekend days (Saturday and Sunday) of the survey. All houses in town were included on the survey. Upon the house visits, one eligible female (20 – 69 years of age) per household was invited to participate in the study, choosing the person through a lottery sampling system. Interviews were conducted on the same day, while blood tests were carried out on the following Monday and Tuesday, at the study centre.
Education was measured in years and the participants were classified in two categories according to their education: (i) low (0 to 7 years of education) and (ii) high (more than 7 years of studies). Age was categorised into four groups: (i) 20-39 years; (ii) 40-49 years; (iii) 50-59 years and (iv) 60-69 years.
The assessment of nutritional habits was carried out using a food-frequency questionnaire designed for this study. The participants were asked to report the average dietary intake (per day, week, month or never consumed) of several food items. Dietary intakes were initially divided into 8 categories: (i) never, (ii) once a month, (iii) 2 to 3 times a month, (iv) 1 to 3 times a week, (v) 4 to 6 times a week, (vi) 1 to 2 times a day, (vii) 3 to 4 times a day, (viii) more than 5 times a day. To assess the influence of dietary habits on total cholesterol and triglyceride, two new categories were constructed: (i) irregular intake (1 to 4 times a month or less); (ii) regular intake (2 or more times a week).
To assess the healthfulness of the dietary habits a rating system based upon Argentinean dietary recommendations was used. From the information on dietary habits that was gathered in this study, this rating system focused on nine types of foods: (i) breads, (ii) biscuits and cakes, (iii) vegetables, (iv) milk and yoghurts, (v) cheese, (vi) meats, (vii) fish, (viii) fast foods and (ix) oils and spreads. An indicator describing unhealthy dietary habits was produced from the following food habits: 1) consuming bread other than whole grain bread, 2) eating biscuits and cakes daily or almost so, 3) not eating vegetables daily, 4) drinking mainly fat-containing milk and yoghurts, 5) eating fat-containing cheese daily, 6) eating mostly high fat meat on a daily basis, 7) eating fish less than twice a week, 8) consum-ing fast foods (hamburgers, pizza, pies) once a week 9) using mainly mayonnaise and butter instead of margarine or oils. The regular consumption of the mentioned items was graded as one point, while the irregular use of the food items was graded as 0 points. This allowed us to grade each diet under study with a value ranging from 0 to 9 possible points, according to the regular or irregular consumption of each of the 9 food groups under study. This type of a rating system has been previously used with adolescents in Haapalahti et al study27.
The blood extractions were performed by biochemists from the Argentinean Biochemist Association. The blood samples were taken starting the Monday, after the questionnaires were performed. A sample of five to ten ml of blood was extracted from each of the participants with a syringe and hypodermic needle, previous hygiene with alcohol 70%. The samples were taken during the morning after the 12 hour fasting period required. The blood samples were gathered in conic tubes. The tubes were submerged in water at 37 °C for 30 minutes. After that, the samples were centrifuged for 5 minutes at 2000 RPM. Plasma was separated in two Eppendorff tubes. One was used to determine total cholesterol and triglycerides and the other was deposited in liquid nitrogen and sent to the city of La Plata to be analyzed by gas chromatography. In La Plata the sample were kept in a freezer at -70 degrees until used to determine then fatty acid composition of each sample. To determine the total cholesterol values Colestat enzymatic method AA (Weiner Lab.) were used. To determine triglyceride values, we used TG Colour GPO/PAP AA from the same laboratory. The analyses were performed in a Technicon RA 1000 auto-analyzer. Total blood cholesterol levels are divided in 3 categories according to the guidelines by National Cholesterol Education Program (NCEP)18: <200 mg/dl (desirable), 200-239 mg/dl (borderline high) and >240 mg/dl (high). Triglycerides levels were divided into 4 categories: < 150 mg/dl, 150-199 mg/dl (borderline high), 200- 499 mg/dl (high), >500 mg/dl (very high triglycerides).
Associations between variables, mainly prevalence proportions, were tested by t-tests and ANOVA using LSD tests for multiple comparisons. Categorical data was tested with chisquare and Mann-Whitney tests. The level of significance was set at p < 0.05. The results are expressed with numbers and relative frequencies (%). Ninety-five percent confidence intervals are reported for all results. Data analyses were carried out with help of SPSS version 11.0 for Windows.
The final study sample consisted of 107 women with a response rate of 87%. Agriculture and farming are the activities which most of the population is involved in. More than half of the women work at home. They cook their own food at home for themselves and their families, and none of the women surveyed eat in restaurants on a regular basis. There were no statistically significant differences between the women included in the study and those 13% which were excluded due to the missing laboratory data. Both groups showed similar characteristics in regard to their age, education and diet.
Table 1 shows the baseline characteristics of the study sample and the consumption of the nine food groups assessed in the survey.
TABLE 1.– Baseline characteristics of the study participants of Cabildo, 2001
The study sample was distributed evenly within the age groups, presenting between 20 and 30% of participants in each of the four categories (20 to 39, 40-49, 50-59 and 60- 69 year olds). Thirty two percent of the women surveyed worked outside their home.
We found that more than half (56%) of the women in Cabildo had 6 years or less of education, and only 14% had started or completed a college or university degree.
The mean total blood cholesterol value for all the women under study was 209 mg/dl. The mean triglyceride value for this study was 124 mg/dl.
Table 2 shows food consumption patterns among the women surveyed. Ninety eight percent of the women surveyed reported daily or almost daily consumption of bread. Whereas 83% reported consuming white bread, only 17% reported eating whole grain bread regularly. The same consumption pattern was seen for the "biscuits and cakes" category. Seventy-seven percent of the women reported daily vegetables intake, and 23% ate vegetables less than three times a week.
TABLE 2.– Food consumption patterns among the study participants in Cabildo, 2001
Milk and cheese was consumed daily by 92% and 93% of the subjects respectively. Forty six percent of the women reported a daily intake of whole fat milk, and 12% reported a whole fat yoghurt everyday. "Hard" cheeses (gruyere, parmesan and others) were consumed by 50% of the participants daily.
Ninety six percent of the subjects reported daily meat consumption. The type of meats most commonly consumed was poultry (70%) followed by beef with high fat content (48%). Regular pork consumption was found in 35% of the participants.
Twenty two percent of the women reported eating canned fish (tuna, anchovies) once a week, and fresh sea fish was reportedly consumed once a week by 34% of the study population.
All of the interviewed women reported frequent consumption of some form of fast food. The most popular among the fast foods was pizza, which was consumed more than twice a week by 62% of the women. Hamburgers and pies were both consumed at least twice a week by 32% of the interviewed.
With regards to the group denominated as "oils and spreads" 58% of the women reported using mayonnaise daily, mainly in the form of salad dressing and other food dressings. Twenty-eight percent of the study population used butter regularly, and only 16% used margarine. Forty-three percent of the women reported not using any kind of spreads on their bread or biscuits. Twenty-nine percent reported daily use of spreads, from these 43% said they used butter, and 12% used margarine. Sunflower oil was the type of oil most frequently used (94%), followed by olive oil, 13%. Seventy-eight percent of the women reported eating fried foods more than once a week. Sunflower oil was the oil most frequently used to do the frying (49%), followed by mixed oils (sunflower and maize oil mix) used by 33%. Forty-nine percent said they used the oil once for frying, 13% used the same frying oil three or more times.
We found a statistically significant difference (p<0.001) between age and total blood cholesterol level (Table 3). As the women get older their total blood cholesterol values increased. No trends between age and mean serum triglyceride values were found.
TABLE 3.– Mean total blood cholesterol and serum triglyceride values according to age-groups in women of Cabildo, 2001
Table 4 shows total blood cholesterol and serum triglycerides ranges based on the recommendations of the Third report of the NCEP18 according to the educational levels of the participants. Among the low educated women 39% had normal total blood cholesterol levels and 61% presented either borderline high or high levels. Eighty percent of these women had normal serum triglyceride levels. Among the high educated women (more than 7 years); 50% had normal blood cholesterol levels, and 70% had normal triglyceride values. There were no statistically significant differences between these groups (p= 0.458 for total blood cholesterol and p= 0.146 for serum triglycerides).
TABLE 4.– Cholesterol and triglyceride categories according to educational groups among Argentinean women in Cabildo, 2001
There were no statistically significant differences in cholesterol levels between groups of women with regular and irregular intake of any food group when analysed individually.
Table 5 presents the nutritional habits between the less and more educated women. The more educated women consumed less bread, biscuits and cakes than did women with fewer years of education. More educated women also reported a lower regular intake of dairy products, meats, butter, margarine, mayonnaise and oils and a higher regular consumption of vegetables than did the less educated participants. Although none of these differences were statistically significant, the mean nutritional risk score based upon a combination of these food choices did differ between the groups. There were no statistically significant differences when age, education and cholesterol levels were tested in combination.
TABLE 5.– Comparison between regular and irregular food intake by groups according to high and low educational levels
The range of the nutritional risk score was 6 to 9 points. Mean nutritional risk score for those with less than 7 years of education was statistically significantly (p= 0.046) higher (8.14) than the total score for those with more than 7 years of education (7.87) (Table 6). There was no statistically significant differences between the nutritional risk score and the age groups.
TABLE 6.– Mean nutritional risk score according to educational levels among 20-69 year old women in Cabildo
Table 7 presents the mean total blood cholesterol and triglyceride levels according to nutritional risk score (NRS). There were no statistically significant differences between the groups.
TABLE 7.– Mean total blood cholesterol and triglyceride levels according to nutritional risk score (NRS) among women of Cabildo, 2001
Based on the results of previous studies19, 20 approximately 20 food products form the basic conventional Argentinean diet: bread, spaghetti and flour derivates, beef, sugar, milk, cheese, sunflower oil, potatoes, green leaf vegetables, rice, oranges, apples, peaches and tomatoes. During the last 20 years, some of these foods, especially those containing meats and saturated fats in various forms have become less important in the everyday diet12-15. In the present study we confirmed that the diet of the participants tended to follow the basic conventional and unhealthy Argentinean diet.
The higher the educational level the better food choices made, and thus a lower risk score, this could be due to the fact that the more educated women have better general knowledge regarding which foods are healthier, and tend to chose these over the others. Another fact that could influence the food choices among these two groups is that the less educated women and their families have a lower income level, thus food prices could be the other important factor influencing the dietary habits of these women. Parada et al.16 already showed this relationship between income and dietary choices when they discovered that lower income populations in Argentina had a diet based on rice and other cereals, with high intakes of meats and low intakes of low-fat milks, while those with more education had higher incomes and their dietary choices were healthier, with a higher consumption of vegetables, low-fat milk and less red meats. These results concur with ours. We think that the socioeconomic factors should be studied in more depth in future investigations.
Most of the bread and biscuits consumed are made with refined flour, which looses many of the vitamins and fibres found on the whole wheat grains. Whole grain bread products are not commonly consumed. Most of the breads and biscuits made in Argentina contain high amounts of trans-fatty acids, butter, and sugar, and few useful minerals and vitamins19, which has been shown to causes adverse effects on the plasma lipoprotein profile2-10, 21. Dairy products are widely consumed in the diet of the women in Cabildo. Almost half of the women in this study reported consumption of whole fat milk and yoghurt. There is lack of information regarding consumption of dairy products for the average Argentinean population. Although low-fat milks and yoghurts are available on the markets they are not widely consumed. We believe that this is due to the fact that they are more expensive than the whole fat dairy products, and so people tend to buy cheaper products. Cheese formed an important part of the average diet. Dairy products are a major source of calcium. In Argentina calcium needs are met mainly through dairy products (68%), followed by cereals in the form of seed and nuts, fruits and different types of vegetables20.
Meat has always been a major part of the Argentinean diet. In this study 96% of the participants reported high consumption of meat, these being mainly poultry and beef. According to research done by the Argentinean National Institute of Technical Nutrition, it has been shown that the intramuscular fat found on beef in the average meat available on the market (1.0 to 1.9g/100g) is equal or has even less than some parts of chicken meat (without skin: 1 to 3.6g/100g). Furthermore it was found that the cholesterol content of the beef produced on the Argentinean Pampas is moderately low (45 to 51mg/100g) mainly due to the way the cattle is bred and it feeds on natural pastures. These values do not differ significantly from those found in chicken (42 to 64 mg/100g)22, 23. The fact that meats in the Argentinean Pampas seem to have lower levels of cholesterol than other meats produced elsewhere could in part explain the non-significant results we found when comparing regular meat intake and total blood cholesterol levels. The meat, especially beef, is usually cooked by oven or barbecued. Cholesterol in the diet comes from beef (55%), eggs (19%) and the rest from chicken, pork, cheese, milk and butter. Iron is provided through meat and eggs, cereals, legumes, roots and fruits20.
Fish is rarely consumed in the average Argentinean diet. This has been an interesting finding since fish is the most important source of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) in a staple diet, which has been shown to decrease cardiovascular heart disease24-26. The addition or complementation of n-3 fatty acids to the Argentinean diet could be an interesting field for future investigation. It was surprising to find that all women under study consumed fast foods regularly. The participants reported preparing and eating fast foods mainly at home, since most women cook at home. Hamburgers and hotdogs are not as popular as pizzas, especially among the older women. However these items are consumed by one-third of the women living in Cabildo on a weekly basis, and pizzas are also prepared mainly at home and during weekends. Mayonnaise is very popular as dressing for several foods and widely consumed. Butter is more popular as bread spread than margarine. The consumption of butter and margarine on the same amounts have shown that butter produces higher blood lipid values (LDL and total cholesterol) over margarine in the review done by Judd, Baer and Clevidence7 on several studies. The oil most commonly used for cooking was sunflower oil. Frying foods is popular and 78% of the participants consume fried foods at least twice a week. Olive oil was used by only 13% of the participants. This is probably due to the high price of this type of oil, and not because of taste.
Although no statistically significant results were obtained when comparing total blood cholesterol and triglyceride values with the nine food groups created, we saw that some trends seem to prevail. It is interesting to note that the mean total blood cholesterol values for the high intake group are all above the internationally recommended values. According to previous studies we know that the high intake of foods such as bread, biscuits, dairy products, meats, fast foods and oils are associated with higher total blood cholesterol values5-10. In our study this trend was not observed among the nutritional groups and serum lipid values. The lack of independent significance between the dietary variables and serum lipids under study does not necessarily mean that the dietary habits of the women of Cabildo contribute nothing to the total blood cholesterol and triglycerides values; it may be that the interactions between the variables and other factors not studied produce a greater effect than the individual variables alone.
Only half of the participants had the recommended total blood cholesterol levels, and more than 50% were on the borderline or high range. Triglyceride values on average were within the normal range (124 mg/dl), according to NCEP18.
As age increases so do total blood cholesterol levels, this results corroborates the results of previous studies done in Argentina15,16. We observed a difference, although not statistically significant between the total blood cholesterol levels, the mean being slightly higher for less educated women (216 vs. 200 mg/dl). When we examined the total blood cholesterol values, education and age of the participants we found no statistically significant results. The younger sample was not the one with more years of education and thus total blood cholesterol or triglyceride levels were not influenced by this factor in this study.
The present study has several limitations. Only nutritional habits, education and blood lipids in the form of cholesterol and triglycerides were studied. Important confounders such as smoking status, physical exercise and body mass index which have been shown to have a strong influence on cholesterol and triglyceride values were not included. The only factor measuring socio-economical status was education. It would have been interesting to have data regarding income. We found that higher educational status influenced positively on the nutritional risk score, however the 95% CI values were broad which made the significant p-value loose specificity. It would have been interesting to see if women with higher income had the same impact. The lack of direct statistically significant association could be partly explained by the fact that it has been demonstrated that cross sectional studies, on their own, are not the best method for detecting relationship between diet and blood lipid values32, 33.
No information regarding cholesterol lowering drug intake was recorded. It is possible that the higher educational groups may be able to afford cholesterol lowering drugs and that they may be better informed on the benefits that this therapy provides. This could be a factor that could have had influenced the overall cholesterol levels within the study sample.
In this study no information was provided regarding the genetic factors which could influence the lipid values of this study. A number of different genes associated with the lipoproteins have beenidentified as involved in genetic predisposition to increased lipid values and produce coronary artery disease; however, the vast majority are not due to genetic conditions such as familial hypercholesterolaemia or other rare disorders of fat metabolism.
In conclusion, this study found no statistically significant associations between consumption of different foods and serum triglyceride and blood cholesterol. The risk score was high, especially among the less educated group of women. This reflects that the overall dietary habits of the women of Cabildo are associated with unhealthy food choices. However nutrition is not the only factor that influences the levels of total blood cholesterol and triglycerides. Factors such as body mass index, physical exercise, smoking status and blood pressure were not studied. Total cholesterol values were higher than those recommended by the NCEP. High fat dairy products, meat, and fast foods are widely consumed, while vegetable consumption is relatively low. More educated women have a lower nutritional risk score. Further studies should be conducted to study whether this is because of higher income or because they have better knowledge regarding nutrition. Educational campaigns regarding healthier food choices could make a positive impact on the health of the population. The benefits of omega 3 fatty acids shown worldwide could improve the diet of this population. Increasing fish intake or adding omega 3 fatty acids to other widely consumed food sources such as bread or eggs could improve the blood lipid profile of these women and have a protective effect on coronary heart diseases. The availability of skimmed milks and yoghurts, as well as a wider selection of low fat cheeses should be ensured. Although all of these food items are available they are significantly more expensive then their whole fat counterparts.
Acknowledgements: The authors would like to thank the town of Cabildo, Graciela Peterson, Donaldo Sicalo, PROPIA (Programa de Prevencion del Infarto en Argentina) and the Department of Public Health and General Practice of the University of Kuopio, Finland, for their help and support. Silvana Gisela Schneider, for her cooperation on the statistical analysis, support and advice.
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