Blood pressure

Observational and clinical studies suggest that milk and dairy intake, particularly low-fat dairy, could have a beneficial effect on blood pressure and contribute to the prevention of hypertension. The DASH (Dietary Approaches to Stop Hypertension) diet, which focuses on fruit and vegetables and low-fat dairy foods, has been found to be an effective way to lower blood pressure.

Milk and dairy foods contain several nutrients and other bioactive components in the dairy matrix including calcium, potassium, phosphorus and bioactive peptides, which may be involved, individually or in combination, in the beneficial effects on blood pressure.

Observational studies

A number of observational studies have noted an association between milk and dairy intake and lower blood pressure, including in European populations. For example, in Welsh men, milk intake predicted systolic blood pressure: in the group with the highest milk intake (around a pint / 586ml of whole milk per day), systolic blood pressure was 10.4 mmHg lower than those who drank little or no milk after a 23-year follow-up1. Similarly, for older people (over 55 years) in the Rotterdam Study, the risk of hypertension decreased with increasing low-fat dairy consumption; although no relationship between dairy and blood pressure was seen in a wider age range of the Dutch population (20–65 years)2,3. In the French DESIR cohort, dairy (milk or yogurt) and cheese consumption were associated with lower diastolic blood pressure after the 9-year follow-up4. Cross-sectional data from the French cohort of the MONICA study also showed higher dairy intake was associated with lower systolic blood pressure5.
A recent analysis of the National Adult Nutrition Survey in Ireland also reports an association between higher total dairy, and specifically milk, intake and lower systolic and diastolic blood pressure6.

In a meta-analysis of five cohort studies, consumption of dairy foods was associated with a 13% reduced risk of elevated blood pressure7. Further analysis suggested that the effect may be driven by low-fat dairy and ‘fluid’ dairy (defined as milk and yogurt); cheese and full-fat dairy foods had no association with risk of high blood pressure. In another meta-analysis, of nine prospective cohort studies in 2012, dairy consumption was also associated with a reduced risk of hypertension8. Again, the effects were specific for low-fat dairy and milk (3% reduction per 200g/day) whereas there was no association for cheese, full-fat dairy, total fermented dairy and, in this case, for yogurt. Both meta-analyses suggest that milk and low-fat dairy could contribute to the prevention of hypertension. This concurred with the US Dietary Guidelines Advisory Committee’s assessment of the science in 2010 which concluded that there was a moderate body of evidence that high intake of milk and milk products is associated with lower blood pressure9; subsequent studies have strengthened this conclusion. A systematic review published in 2016 of the association between dairy product consumption and risk of various cardiovascular-related clinical outcomes reports favourable associations between intakes of total dairy, low-fat dairy and milk and the risk of hypertension10.

The DASH diet

The best known intervention involving dairy, the DASH (Dietary Approaches to Stop Hypertension) diet, has proved an effective way to lower blood pressure in those with and without hypertension11-13. The DASH eating plan, which emphasises fruit, vegetables, wholegrains and low-fat dairy products (around 3 servings a day), has been widely promoted in the USA for the prevention and treatment of high blood pressure14. Although this intervention was first conducted as a feeding trial, further studies have found that DASH dietary advice can also be effective at lowering blood pressure in free-living populations15,16. European guidelines on the management of hypertension now also include a ‘DASH diet’ approach recommending increased consumption of vegetables, fruits, and low-fat dairy products17. Observational studies have suggested that in children too, a ‘DASH’ dietary pattern may have beneficial effects on blood pressure18,19. A recent trial has also indicated that when higher-fat dairy foods are incorporated into the DASH pattern, blood pressure lowering effects are still evident20. In addition, three controlled trials which examined the impact of dairy products per se on blood pressure (rather than as part of a dietary pattern such as DASH) reported beneficial effects21-23. These included an intervention using full-fat hard cheese (two months of 30g/day of Grana Padano) compared with a placebo consisting of flavoured bread mixed with fats and salts in the same concentrations as the cheese23.

Potential dairy matrix mechanisms

Milk and dairy foods contain several nutrients and other bioactive components which have been associated with blood pressure control. Recent research has focused on the importance of bioactive peptides in the regulation of blood pressure, including those from dairy. For example, a group of peptides (lactotripeptides), released from milk and dairy products during digestion of casein proteins in the gut or by fermentation, have been shown to have anti-hypertensive properties and to regulate blood pressure by inhibiting ACE-1, a potent vasoconstrictor24-26. Similarly, in a recent clinical trial, whey protein also lowered blood pressure and improved endothelial function in adults with pre-hypertension and mild hypertension27.

Blood pressure-lowering effects of the B vitamin riboflavin, of which milk is a good source, have also been reported28. This reflects the role of riboflavin in regulation of homocysteine levels in those with a genetic defect in homocysteine metabolism (about 10% of the European population); an elevated level of homocysteine has been associated with hypertension29.

The minerals in milk including calcium, potassium and magnesium are also linked to blood pressure regulation through their effects on intracellular mechanisms and production of vasodilators30-31Calcium, for example, may have a direct impact on blood pressure through effects on vascular smooth muscle, as well as through parathryroid hormone (PTH) and vitamin D secretion, and increased sodium excretion31Phosphorus in dairy may be involved too31. A recent study reported that phosphorus from dairy products, but not from other sources, was associated with lower baseline blood pressure and reduced risk of hypertension32. This may indicate that the benefits of phosphorus are dependent on interactions with other dairy components. Indeed, it is likely that the blood pressure lowering effects of milk and dairy products are the results of interactions between the constituents of the dairy matrix33.

The weight of the evidence to date suggests that milk and dairy foods, particularly low-fat dairy, can help lower blood pressure and contribute to the prevention of hypertension. This is important given that high blood pressure is a major risk factor for cardiovascular disease, particularly stroke, and even values at the high end of the normal range increase the risk. Around 30% to 45% of the European population has hypertension, with a steep increase with ageing, so even small reductions in prevalence could have public health benefit17.

References

 

1. Livingstone KM et al. Does dairy food intake predict arterial stiffness and blood pressure in men? Evidence from the Caerphilly Prospective Study. Hypertension. 2013; 61: 42-47.

2. Engberink MF et al. Inverse association between dairy intake and HTN: The Rotterdam Study. Am J Clin Nutr. 2009; 89: 1877-1883.

3. Engberink MF et al. Dairy intake, blood pressure, and incident HTN in a general Dutch population. J Nutr. 2009; 139: 582-587.

4. Fumeron F et al. Dairy products and the metabolic syndrome in a prospective study, DESIR. J Am Coll Nutr. 2011; 30(5 Suppl 1): 454S-463S.

5. Ruidavets JB et al. Independent contribution of dairy products and calcium intake to blood pressure variations at a population level. J Hypertens. 2006; 24: 671-681.

6. Feeney EL et al. Patterns of dairy food intake, body composition and markers of metabolic health in Ireland: results from the National Adult Nutrition Survey. Nutr Diabetes. 2017; 7: e243; doi:10.1038/nutd.2016.54.

7. Ralston RA et al. A systematic review and meta-analysis of elevated blood pressure and consumption of dairy foods. J Hum Hypertens. 2012; 26: 3-13.

8. Sodamah-Muthu SS et al. Dairy consumption and incidence of hypertension: a dose response meta-nnalysis of prospective cohort studies. Hypertension. 2012; 60: 1131-1137.

9. Dietary Guidelines Advisory Committee. Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans, 2010. Washington, DC: US Department of Agriculture, Agricultural Research Service; 2010. http://www.cnpp.usda.gov/Publications/DietaryGuidelines/2010/DGAC/Report/2010DGACReport-camera-ready-Jan11-11.pdf (accessed 11/12/13).

10. Drouin-Chartier J-P et al. Systematic review of the association between dairy product consumption and risk of cardiovascular-related clinical outcomes. Adv Nutr. 2016; 7: 1026–1040.

11. Appel LJ et al. A clinical trial of the effects of dietary patterns on blood pressure. DASH Collaborative Research Group. N Engl J Med. 1997; 336: 1117-1124.

12. Sacks FM et al. Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. DASH-Sodium Collaborative Research Group. N Engl J Med. 2001; 344: 3-10.

13. Siervo M et al. Effects of the Dietary Approach to Stop Hypertension (DASH) diet on cardiovascular risk factors: a systematic review and meta-analysis. Br J Nutr. 2015; 113: 1-15.

14. US Department of Health and Human Services, National Institutes of Health, National Heart, Lung, and Blood Institute.  Your guide to lowering your blood pressure with DASH (NIH Publication No. 06-4082). Bethesda, Maryland: NIH; 2006. http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf (accessed 6/12/13).

15. Appel LJ et al. Effects of comprehensive lifestyle modification on blood pressure control: main results of the PREMIER clinical trial. JAMA. 2003; 289: 2083-2093.

16. Harnden KE et al.  Dietary Approaches to Stop Hypertension (DASH) diet: applicability and acceptability to a UK population.  J Hum Nutr Diet. 2010; 23: 3-10.

17. Mancia G et al. 2013 ESH/ESC Guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens. 2013; 31: 1281–1357.

18. Moore LL et al. Intake of fruits, vegetables, and dairy products in early childhood and subsequent blood pressure change. Epidemiology. 2005; 16: 4-11.

19. Asghari G et al. Dietary Approaches to Stop Hypertension (DASH) dietary pattern is associated with reduced incidence of metabolic syndrome in children and adolescents. J Pediatr. 2016; 174: 178-184.

20. Chiu S et al. Comparison of the DASH (Dietary Approaches to Stop Hypertension) diet and a higher-fat DASH diet on blood pressure and lipids and lipoproteins: a randomized controlled trial. Am J Clin Nutr. 2016; 103: 341-347

21. Drouin-Chartier JP et al. Impact of dairy consumption on essential hypertension: a clinical study. Nutr J. 2014; 13: 83.

22. Machin DR et al. Hypotensive effects of solitary addition of conventional nonfat dairy products to the routine diet: a randomized controlled trial. Am J Clin Nutr. 2014; 100: 80-87.

23. Crippa G et al. Os 04-04 Antihypertensive effect of milk-derivative tripeptides. Randomized, double-blind, placebo-controlled study on the effects of Grana Padano cheese dop in hypertensive patients. J Hypertens. 2016; 34 Suppl 1: e55-56.

24. Ricci I et al. Milk protein peptides with angiotensin I-converting enzyme inhibitory (ACEI) activity. Crit Rev Food Sci Nutr. 2010; 50: 390-402.

25. Fekete AA et al. Casein-derived lactotripeptides reduce systolic and diastolic blood pressure in a meta-analysis of randomised clinical trials. Nutrients. 2015; 7: 659-681.

26. Neilsen R et al. Short communication: Is consumption of a cheese rich in angiotensin-converting enzyme-inhibiting peptides, such as the Norwegian cheese Gamalost, associated with reduced blood pressure? J Dairy Sci. 2014; 97: 2662–2668.

27. Fekete AA et al. Whey protein lowers blood pressure and improves endothelial function and lipid biomarkers in adults with prehypertension and mild hypertension: results from the chronic Whey2Go randomized controlled trial. Am J Clin Nutr. 2016; 104: 1534-1544.

28. Wilson CP et al. Riboflavin offers a targeted strategy for managing hypertension in patients with the MTHFR 677TT genotype: a 4-y follow-up. Am J Clin Nut. 2012; 95: 766-772.

29. McNulty et al. Riboflavin lowers homocysteine in individuals homozygous for the MTHFR 677C->T polymorphism. Circulation. 2006; 113: 74-80.

30. Houston MC & Harper KJ. Potassium, magnesium, and calcium: their role in both the cause and treatment of hypertension.  J Clin Hypertens. 2008; 10: 3-11.

31. McGrane MM et al. Dairy consumption, blood pressure, and risk of hypertension: An evidence-based review of recent literature. Curr Cardiovasc Risk Rep. 2011; 5: 287-298.

32. Alonso A et al. Dietary phosphorus, blood pressure, and incidence of hypertension in the atherosclerosis risk in communities study and the multi-ethnic study of atherosclerosis. Hypertension. 2010; 55: 776-784.

33. Thorning TK et al. Whole dairy matrix or single nutrients in assessment of health effects: current evidence and knowledge gaps. Am J Clin Nutr 2017: 105:1–13.

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