Keywords
inflammation - cardiovascular disease - menopause - dietary pattern - physical activity
Palavras-chave
inflamação - doença cardiovascular - menopausa - padrões dietéticos - atividade física
Introduction
Cardiovascular disease (CVD) is still the leading cause of death among postmenopausal
women worldwide.[1]
[2] The pathophysiology of CVD is associated with atherosclerosis, a progressive process
that usually begins in childhood and presents subclinical alterations or clinical
manifestations from adulthood.[3]
Inflammation is the key mechanism in the pathogenesis of atherosclerosis.[3]
[4] The inflammatory process associated with atherosclerosis is difficult to estimate
directly. Therefore, biomarkers of inflammation have been the object of growing interest.[3]
[5] Among the acute-phase proteins, C-reactive protein has good stability, high sensitivity,
good reproducibility, and precision as such a marker.[5] High-sensitivity CRP (hs-CRP) is associated with cardiovascular risk factors in
postmenopausal women, such as central fat distribution, insulin resistance, blood
pressure and lipid profile.[6]
Diet is a major modifiable risk factor for CVD.[7] The glycemic index (GI) and glycemic load (GL), which reflect the propensity of
carbohydrate to raise blood glucose levels, have gained increasing importance.[8] High-GI and high-GL diets have been associated with increased risk of coronary heart
disease and stroke.[9]
Therefore, the aim of the present study was to assess whether diet, metabolic profile,
body composition and physical activity are associated with low-grade chronic inflammation,
as determined by hs-CRP levels among a sample of postmenopausal women.
Methods
Subjects
This cross-sectional study was performed at Hospital de Clínicas de Porto Alegre,
Brazil, from October 2010 to February 2012. Participants were recruited by advertisement
in a local newspaper and radio station.[10] Postmenopausal women aged 45–65 years and presenting with at least 1 year of amenorrhea
and follicle-stimulating hormone (FSH) levels > 35mIU/mL were included. The exclusion
criteria were use of hormone therapy or anti-inflammatory agents (current or in the
preceding 3 months), untreated thyroid disease, previous diagnosis of cardiovascular
disease, diabetes mellitus or rheumatic diseases, and smoking. The study protocol
was approved by the local Research Ethics Committee, and written informed consent
was obtained from every subject.
Study Protocol
All participants completed a questionnaire about their sociodemographic characteristics.
Blood pressure was measured using a digital sphygmomanometer (HEM-742, Omron, Rio
de Janeiro, Brazil) after 10 minutes of rest, with participants in the sitting position.
Hypertension was defined as a blood pressure ≥140/90 mm Hg or by the regular use of
antihypertensive drugs.
Anthropometric measurements were obtained in duplicate and included body weight, height,
and waist circumference (WC).[11]
[12] Body mass index (BMI, kg/m2) was calculated. Body composition was assessed by bioelectrical impedance analysis
(BIA) (Inbody230, Biospace Inc., Los Angeles, USA). All blood samples were obtained
between 8 and 10 am, after a 12-hour fast. Metabolic syndrome was diagnosed as defined in the Joint Scientific
Statement.[13] Participants were stratified in two groups according to hs-CRP as < 3 mg/L or ≥3
mg/L.
Assays
Total cholesterol, high-density lipoprotein cholesterol (HDL-c), and triglycerides
(TG) were determined by colorimetric-enzymatic methods (Bayer 1800 Advia System, Mannheim,
Germany), with intra- and interassay coefficients of variation (CV) <3%. Glucose was
quantitated by the hexokinase method (Advia 1800, Mannheim, Germany), with an intra-
and interassay CV <3.4%. A validated high-sensitivity nephelometric method (Dade Behring
Marburg, Marburg, Germany) was used for hs-CRP analysis in stored specimens, with
a sensitivity of 0.17 mg/L and intra- and interassay CVs of 4.4 and 5.7% respectively.
Individual results below the limit of sensitivity of the test (≤ 0.17) were considered
as equal to 0.17 mg/L for statistical analysis. Follicle- stimulating hormone (FSH)
levels were measured by chemiluminescence immunoassay (CLIA) (Centaur XP, Mannheim,
Germany). Serum insulin levels were measured using CLIA (Centaur XP), with a sensitivity
of 0.200 μIU/mL and intra- and interassay CVs of 2.0 and 4.3% respectively. Low-density
lipoprotein cholesterol (LDL-c) was calculated using the Friedewald formula. The homeostasis
model assessment of insulin resistance (HOMA-IR) index was calculated by multiplying
insulin (μIU/mL) by glucose (mmol/L) and dividing this product by 22.5, and the lipid
accumulation product (LAP) was calculated using the formula: LAP = (WC – 58) × TG.[14]
[15]
Dietary Assessment
Usual dietary intake in the last month before the study was assessed with a validated
food frequency questionnaire consisting of 120 items.[16] Nutritional composition was calculated using the Brazilian Table of Food Composition
(NEPA-UNICAMP, Campinas, Brazil), except for vitamin D, E, and A, which were assessed
using the United States Department of Agriculture (USDA) National Standard Reference
Database. The glycemic index (GI) and GL were calculated according to standards proposed
by the Food and Agriculture Organization (FAO) from the International Tables of Glycemic
Index and Glycemic Load Values, with glucose used as reference.[17]
Physical Activity Assessment
Habitual physical activity was assessed with a digital pedometer (BP 148, Tech Line,
São Paulo, Brazil). The device was configured individually according to weight (kg)
and individual step length, and worn for 6 consecutive days, providing a weekly average
number of steps. Subjects were recommended not to change their physical activity habits
during the study. Those who walked fewer than 6 thousand steps a day were considered
inactive.[18]
[19]
Statistical Analyses
The healthy group (hs-CRP <3 mg/L) and the group presenting low-grade chronic inflammation
(hs-CRP ≥3 mg/L) were defined according to the National Academy of Clinical Biochemistry
Laboratory Medicine Practice Guidelines.[20] Patients with hs-CRP ≥10 mg/L were excluded from analysis, because this value might
be indicative of acute inflammation.[20] Results are presented as mean ± standard deviation (SD) or median and interquartile
range for normally and non-normally distributed variables respectively. The two-tailed
Student's t-test or the Wilcoxon–Mann–Whitney U test were used to compare the differences
between means of parametric and nonparametric data respectively. The Chi-square (χ2) test was calculated for comparisons of dichotomous variables. A logistic regression
model was used to estimate the odds ratio of different variables for high hs-CRP,
which was considered the dependent variable. All analyses were performed in the SPSS
19.0 environment (SPSS Inc., Chicago, IL, USA). Data were deemed significant at p < 0.05.
Results
Out of 119 volunteers, 5 were excluded for diabetes mellitus, 1 for heart disease,
1 for hyperthyroidism, 2 for untreated hypothyroidism, 2 for breast cancer, and 1
for premenopausal status. An additional 3 participants dropped out because they were
unable to commit to the study (no free time for blood collection), and 9 had hs-CRP
levels ≥10 mg / L. Thus, 95 women were enrolled to the study.
[Table 1] shows demographic, metabolic and hormonal profiles as well as body composition-related
variables of participants stratified by hs-CRP levels (< 3 or ≥3 mg/L). The mean age
of the sample was 54.7 ± 4.8 years, and the mean duration of menopause was 6.5 ± 4.0
years. Age, duration of menopause, race and educational attainment were similar in
both groups. However, the hs-CRP < 3 mg/L group exhibited lower BMI, WC, body fat
percentage, body fat mass in comparison with the hs-CRP ≥3 mg/L group (p < 0.01). The median number of steps walked per day was greater in women with lower
levels of hs-CRP, and the prevalence of sedentary lifestyle was lower (49% versus
78%, p = 0.02). The hs-CRP < 3 mg/L group had higher HDL-c levels and lower TG, fasting
glucose, insulin, HOMA-IR, and LAP in comparison with the hs-CRP ≥3 mg/L group. Metabolic
syndrome was also more frequent in the hs-CRP ≥3 mg/L group.
Table 1
Characteristics of 95 postmenopausal women stratified by hs-CRP level
|
Overall
|
<3 mg/dL
|
≥3 mg/dL
|
p-value
|
|
n = 95
|
n = 72
|
n = 23
|
|
|
Age (years)[a]
|
54.7 ± 4.8
|
54.7 ± 5.0
|
55.3 ± 4.1
|
0.58
|
|
Time since menopause (years)[b]
|
5.0
(2.0–10.0)
|
5.0
(3.0–10.0)
|
4.5
(2.9–8.0)
|
0.46
|
|
Years at school[b]
|
8.0
(5.0–11.0)
|
8.0
(5.0–11.0)
|
8.0
(5.0–11.0)
|
0.79
|
|
White, n (%)[c]
|
83
(87.4)
|
61
(84.7)
|
22
(95.6)
|
0.28
|
|
BMI (kg/m2)[b]
|
26.2
(23.8–29.1)
|
25.3
(23.1–28.0)
|
29.9
(25.0–32.0)
|
< 0.01
|
|
WC (cm)[b]
|
84.5
(78.0–91.0)
|
83.0
(76.2–87.4)
|
94.0
(89.0–101.5)
|
< 0.01
|
|
Lean mass (kg)[b]
|
23.4
(8.5–33.1)
|
22.6
(21.1–25.4)
|
23.9
(21.3–26.8)
|
0.31
|
|
Fat mass (kg)[b]
|
23.9
(36.0–120.0)
|
21.3
(17.0–26.5)
|
30.3
(24.0–34.4)
|
< 0.01
|
|
% Fat mass[a]
|
35.4 ± 7.0
|
33.6 ± 6.6
|
40.9 ± 5.0
|
< 0.01
|
|
TC (mg/dL)[a]
|
217.7 ± 35.5
|
216.9 ± 36.8
|
220.4 ± 31.7
|
0.38
|
|
HDL-c (mg/dL)[b]
|
53.0
(45.0–63.0)
|
53.0
(46.2–64.7)
|
48.0
(41.0–52.0)
|
0.02
|
|
LDL-c (mg/dL)[b]
|
137.4
(117.3–159.0)
|
135.9
(116.8–156.7)
|
143.6
(122.9–161.2)
|
0.45
|
|
TG (mg/dL)[b]
|
98.0
(73.0–146.0)
|
88.5
(72.0–138.5)
|
134.0
(98.0–208.0)
|
0.01
|
|
Glucose (mg/dL)[a]
|
92.8 ± 8.4
|
91.5 ± 7.5
|
97.1 ± 9.6
|
< 0.01
|
|
Insulin (µUI/mL)[b]
|
8.8
(5.9–13.9)
|
7.9
(5.7–12.1)
|
14.7
(8.1–19.5)
|
< 0.01
|
|
HOMA-IR[b]
|
2.0
(1.3–3.3)
|
1.8
(1.3–2.8)
|
3.2
(1.7–4.5)
|
0.01
|
|
LAP[b]
|
30.8
(17.8–45.9)
|
25.2
(17.3–38.1)
|
45.9
(32.7–65.3)
|
< 0.01
|
|
Hypertension (%)[c]
|
37 (39%)
|
27 (37%)
|
10 (43%)
|
0.67
|
|
Metabolic syndrome[c]
|
18 (19%)
|
8 (11%)
|
10 (43%)
|
< 0.01
|
|
Mean steps a day[b]
|
5,258
(3,662–8,227)
|
6,069
(4,315–8,394)
|
3,961
(2,310–5,962)
|
< 0.01
|
Abbreviations: BMI, body mass index; HDL-c, HDL cholesterol; HOMA-IR, homeostasis
model assessment of insulin resistance; LAP, lipid accumulation product; LDL-c, LDL
cholesterol; n, number; TC, total cholesterol; TG, triglycerides; WC, waist circumference.
a Student's t-test,
b Mann–Whitney–Wilcoxon U test,
c Chi-square Test.
Regarding dietary intake ([Table 2]), there was a lower energy intake from carbohydrate and higher from protein in the
hs-CRP <3 mg/L group. Energy intake from fat was similar between groups, and while
saturated fat was slightly higher in the the hs-CRP <3 mg/L group, values were in
accordance with reference ranges. Dietary GL was lower in the hs-CRP <3 mg/L group,
and GI was similar between the groups. Vitamin E intake was markedly below the reference
values in both groups.
Table 2
Dietary intake in 95 postmenopausal women stratified by hs-CRP level
|
Daily intake
|
< 3 mg/dL
|
≥3 mg/dL
|
p-value
|
Reference range
|
|
n = 72
|
n = 23
|
|
Total Kcal[b]
|
1,716.8
(1,418.8–2,217.3)
|
2,053.3
(1,415.0–2,584.7)
|
0.18
|
−
|
|
% Carbohydrate Kcal[b]
|
55.4
(50.4–58.4)
|
61.3
(55.9–65.1)
|
< 0.01
|
45–65[*]
|
|
Carbohydrate (g)[b]
|
244.5
(186.6–309.0)
|
295.4
(202.3–397.3)
|
0.06
|
130[*]
|
|
Glycemic load (g)[b]
|
128.4
(95.4–153.3)
|
152.0
(111.5–197.3)
|
0.04
|
< 120[#]
|
|
Glycemic index (%)[b]
|
55.5
(51.8–58.4)
|
55.9
(52.7–58.3)
|
0.72
|
ND
|
|
Fiber (g)[b]
|
25.3
(19.3–34.1)
|
28.6
(20.8–43.3)
|
0.14
|
25[*]
|
|
% Protein Kcal[a]
|
16.9 ± 2.7
|
15.1 ± 3.5
|
0.03
|
10–35[*]
|
|
Protein (g)[b]
|
79.1
(57.5–90.8)
|
70.4
(64.6–94.5)
|
0.65
|
46[*]
|
|
% Fat Kcal[a]
|
24.1 ± 5.6
|
21.6 ± 5.3
|
0.06
|
20–35[*]
|
|
Fat (g)[b]
|
48.3
(32.0–61.5)
|
48.4
(37.3–54.2)
|
0.91
|
ND
|
|
SFA (%)[a]
|
7.1 ± 2.1
|
6.0 ± 1.6
|
0.03
|
< 10%[d]
|
|
PUFA (%)[a]
|
3.3 ± 1.0
|
3.3 ± 1.0
|
0.74
|
ND
|
|
MUFA (%)[b]
|
7.0
(5.8–8.8)
|
6.6
(5.1–7.4)
|
0.10
|
ND
|
|
Cholesterol (mg)[b]
|
183.2
(132.1–254.6)
|
210.1
(108.1–255.9)
|
0.98
|
< 300[b]
|
|
Calcium (mg)[b]
|
721.1
(509.9–999.2)
|
794.1
(462.8–944.8)
|
0.73
|
1,200[*]
|
|
Magnesium (mg)[b]
|
238.9
(190.0–315.4)
|
289.0
(195.8–387.5)
|
0.19
|
320[*]
|
|
Iron (mg)[b]
|
8.2
(6.4–11.4)
|
10.6
(6.7–14.1)
|
0.12
|
8[*]
|
|
Zinc (mg)[b]
|
7.9
(5.9–9.7)
|
8.0
(6.3–9.8)
|
0.72
|
8[*]
|
|
Sodium (mg) [a]
|
1,785.8
(1,415.8–2,204.6)
|
1,839.2
(1,564.1–2,448.7)
|
0.22
|
< 1,500[*]
|
|
Selenium (µg)[b]
|
88.9
(64.5–111.9)
|
91.3
(71.6–106.8)
|
0.82
|
55[*]
|
|
Folate (µg)[b]
|
490.1
(361.1–645.4)
|
480.7
(406.1–947.6)
|
0.47
|
400[*]
|
|
Vitamin D (µg)[b]
|
4.6
(2.4–10.6)
|
2.7
(1.9–7.1)
|
0.13
|
10–15[*]
|
|
Vitamin B12 (µg)[b]
|
4.4
(3.1–5.7)
|
3.2
(2.2–4.2)
|
0.07
|
2.4[*]
|
|
Vitamin E (mg)[b]
|
3.5
(2.5–4.7)
|
4.8
(2.9–6.0)
|
0.04
|
15[*]
|
|
Vitamin C (mg)[b]
|
157.1
(106.7–272.0)
|
207.6
(114.7–478.4)
|
0.33
|
75[*]
|
|
Vitamin A (µg)[b]
|
699.7
(451.3–1,170.8)
|
859.2
(364.6–1,747.1)
|
0.47
|
700[*]
|
Abbreviations: Kcal, kilocalories; MUFA, monounsaturated fatty acid; n, number; PUFA,
polyunsaturated fatty acid; SFA, saturated fatty acid.
a Student's t-test,
b Mann–Whitney–Wilcoxon U test, c Chi-square Test.
* Institute of Medicine,[21]
# Atkinson et al.[17];
d I Brazilian Society for Cardiology and Brazilian Menopause Association Guideline
on the Prevention of Cardiovascular Disease in Menopausal Women and the Influence
of Hormone Therapy, 2008.[22]
After adjustment for age and duration of menopause, the odds ratio for hs-CRP ≥3 mg/L
was higher with sedentary lifestyle, body fat percentage, WC (> 88 cm), and carbohydrate
intake above 55% of total calories, that was the median of this sample; however, GL
(>120 g) did not influence the odds ratio for increased hs-CRP ([Table 3]).
Table 3
Odds ratios for hs-CRP ≥3 mg / L
|
Variable
|
OR
|
95% CI
|
p-value[a]
|
|
% Carbohydrate Kcal (>55)
|
2.9
|
1.1–7.7
|
0.03
|
|
Glycemic load (>120 g)[b]
|
1.8
|
0.6–5.0
|
0.30
|
|
Sedentary lifestyle (<6,000 steps/day)
|
4.7
|
1.4–15.5
|
0.01
|
|
Waist Circumference (≥88 cm)[c]
|
13.6
|
3.9–47.0
|
< 0.01
|
|
% Body fat[d]
|
18.7
|
2.2–155.9
|
0.01
|
Abbreviations: CI, confidence interval; Kcal, kilocalories; OR, odds ratio.
a Logistic regression adjusted for age and time since menopause;
b International Tables of Glycemic Index and Glycemic Load Values: 2008[17];
c Waist circumference ≥88 cm[13];
d % Body fat ≥34% for subjects aged 40–59 years and ≥36% for subjects aged ≥60 years.[23]
Discussion
In the present study, a sample of postmenopausal women from Southern Brazil presenting
no evidence of clinical disease was stratified according to the presence or absence
of low-grade inflammation as a non-conventional marker for cardiovascular risk. Those
with hs-CRP levels < 3 mg/L had better anthropometric, metabolic, and hormonal profiles
than women with hs-CRP levels ≥3 mg/L. Sedentary lifestyle and high-carbohydrate dietary
intake were associated with central adiposity and metabolic syndrome, and contributed
to low-grade chronic inflammation and risk of CVD in this sample, even after adjustment
for potential confounders, including age and duration of menopause.
We observed an association between hs-CRP, body fat, and WC. These results corroborate
data described in previous studies.[6]
[24] In fact, adipocyte hypertrophy can cause hypoxia, stimulating the activation of
intracellular NF-κB, which plays a key role in regulating immune response and induces
production of tumor necrosis factor-α (TNF-α) and interleukins (IL) and, consequently,
an increase in hs-CRP.[20]
[24] This is the possible mechanism for increased levels of hs-CRP and inflammatory cytokines,
such as IL-6 and TNF-α, among obese individuals, and may explain why these increases
correlate positively with BMI.[25]
Studies with postmenopausal women have also shown an increased prevalence of insulin
resistance, which is related to an adverse profile of weight and body fat distribution.[11]
[26]
[27] In the present study, beyond higher circulating concentrations of glucose and insulin,
as well as HOMA-IR, we found a higher LAP index in women with hs-CRP ≥3 mg/L. These
data extend previous results obtained by our research group, in which postmenopausal
women stratified by LAP > 34.5 also had higher levels of hs-CRP, suggesting an increased
risk of cardiovascular disease.[14]
Regarding lipoprotein metabolism, we observed an association of hs-CRP ≥3 mg/L with
lower HDL-c and higher TG levels, but not with total cholesterol and LDL-c levels.
These changes may be related to insulin resistance, which was more prevalent in the
hs-CRP ≥3 mg/L group. A similar result was observed by Moreto et al,[28] who reported higher levels of HDL-c and lower levels of TG in Brazilian adults with
hs-CRP < 3 mg/L in comparison to adults with hs-CRP > 3 mg/L.
Being physically active (in this study, defined as walking ≥6 thousand steps per day)
was inversely associated with hs-CRP levels, confirming the results of studies with
younger[29] or obese women populations[30] that also reported an inverse relationship between inflammation and physical activity.
The mechanisms involved with the beneficial effect of exercise seem to be related
to the cytokines produced by muscle cells, which could exert a protecting role against
chronic diseases associated with low-grade inflammation, including improvement on
endothelial function and nitric oxide synthesis.[31]
In the present study, while no difference in total energy intake was found between
groups, women with hs-CRP levels ≥3 mg/L consumed more carbohydrates and had a higher
GL. Carbohydrate is the main dietary component affecting insulin secretion and postprandial
glycemia.[8] High-GL diets are associated with compensatory hyperinsulinemia, lipid metabolic
disorders, and they induce inflammation owing to excess cellular glucose concentrations.[32]
[33]
[34] A meta-analysis with observational studies shows that low-GL diets are independently
associated with a reduced risk of chronic diseases, and supports the hypothesis that
higher postprandial glycaemia is a universal mechanism for disease progression.
In turn, in our study, participants with hs-CRP levels ≥3 mg/L consumed a diet that
was slightly lower in protein. Hu (2005)[35] suggests that there is a potential beneficial effect of replacing high-GI refined
carbohydrates with protein to reduce cardiovascular risk.[35]
The strengths of our study include providing data from postmenopausal women with no
evidence of clinical diseases. The limitation of the study is that, because of its
design, we could not establish whether a causal relationship exists between dietary
patterns – specifically, a higher intake of carbohydrates and a higher GL – and higher
risk of CVD in postmenopausal women. Thus, further longitudinal studies or randomized
clinical trials are needed to test this hypothesis.
In conclusion, in this sample of postmenopausal women, hs-CRP levels <3 mg/L were
associated with better anthropometric, metabolic, and hormonal profiles, and a lower
prevalence of the metabolic syndrome than hs-CRP levels ≥3 mg/L. Sedentary lifestyle
and carbohydrate intake accounting for more than 55% of total energy intake were associated
with higher body fat percentage and larger WC, as well as a higher odds ratio for
cardiovascular risk, as stratified by hs-CRP ≥3 mg/L.
