American Journal of Epidemiology

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Original Contribution

Milk, Fruit and Vegetable, and Total Antioxidant Intakes in Relation to Mortality
Rates: Cohort Studies in Women and Men

Karl Michaëlsson*, Alicja Wolk, Håkan Melhus, and Liisa Byberg
* Correspondence to Dr. Karl Michaëlsson, Department of Surgical Sciences, Faculty of Medicine, Uppsala University,
SE-751 85 Uppsala, Sweden (e-mail: karl.michaelsson@surgsci.uu.se).

Initially submitted October 30, 2015; accepted for publication April 22, 2016.

High milk consumption might shorten life span through increased oxidative stress. We aimed to determine
whether higher mortality rates with high milk consumption are modified by fruit and vegetable intake or total anti-
oxidant intake (oxygen radical absorbance capacity). We used information from food frequency questionnaires
completed by 61,420 women in a Swedish cohort (22,391 deaths from the 1987–1990 baseline onward), 36,714
women from a second survey (1997) of this cohort, and 45,280 Swedish men (15,478 deaths from the 1998 base-
line onward). Compared with low consumption of milk (<1 glass/day) and high consumption of fruits/vegeta-
bles (≥5 servings/day), time-updated information revealed an adjusted hazard ratio for death of 2.79 (95%
confidence interval (CI): 2.42, 3.21) in women who consumed ≥3 glasses of milk/day and <1 serving/day of fruit/
vegetables and a hazard ratio of 1.60 (95% CI: 1.40, 1.82) in women who consumed the same amount of milk but
≥5 servings/day of fruits/vegetables. The same comparisons in men, based on a single food frequency question-
naire, displayed hazard ratios of 1.31 (95% CI: 1.14, 1.51) and 1.07 (95% CI: 0.97, 1.18), respectively. Total anti-
oxidant consumption showed similar patterns as fruit/vegetable intakes. Dietary antioxidant intake, especially in
women, seems to modify the elevated death rate associated with high milk consumption.

antioxidants; fruit; galactose; lactose; milk; mortality; oxidative stress; vegetables

Abbreviations: CI, confidence interval; FFQ, food frequency questionnaire; GALT, galactose-1-phosphate uridylyltransferase;
HR, hazard ratio; ORAC, oxygen radical absorbance capacity; SD, standard deviation; SMC, Swedish Mammography Cohort.

High milk consumption has long been promoted as disease and cancer in humans (9, 10) but also a mechanism of
strengthening bone and reducing the likelihood of fragility age-related bone loss and sarcopenia (10, 11).
fractures. However, we recently demonstrated a higher risk of Oxidative stress and inflammation can be reduced by a diet
fracture with high daily milk consumption in women (1). rich in antioxidants (12–15), and such foods could potentially
Mortality rates were also increased in both women and men reduce rates of death (16, 17). Because of the antioxidant cap-
with high milk consumption. We hypothesized that the under- acity of vegetables and fruits and the high content of lactose/
lying mechanism could be explained by the lactose content of galactose in milk, which may induce oxidative stress and
milk (1). low-grade inflammation, we hypothesized that a high intake
Milk is the main dietary source of D-galactose, one compo- of fruits and vegetables or a high total antioxidant intake
nent of the disaccharide lactose. Chronic D-galactose exposure (18, 19) may counteract the observed associations of milk in-
in animals, with a dose corresponding to 1–2 glasses of milk take with mortality. Indeed, experimental evidence in animals
in humans (1, 2), is deleterious to health by means of oxida- indicates that galactose-induced aging can be prevented by a
tive stress damage and chronic inflammation (2–5). Female higher intake of fruits and vegetables (20–24).
animals seem to be especially vulnerable (6–8). The increased To our knowledge, no previous clinical study has com-
oxidative stress with aging and chronic low-grade inflamma- bined milk consumption with fruit and vegetable intake and
tion is not only a pathogenic mechanism of cardiovascular total antioxidant intake to evaluate associations with the rate

1

and 99. ranged between 0. method (28). and 13 the Swedish Cause of Death Registry.030 women preted as no intake of that particular food (33). 2015. but in women we each food by its ORAC concentration (μmol Trolox equiva- also used time-updated information by means of the complete lents (TE)/100 g) (Trolox: F. Because antioxidants in coffee and tea have Ethical Review Board in Stockholm. with a higher number of items over We used data from 2 previously described (1) population. We considered as the primary outcome all-cause mortal- sour milk. from the Swedish National Food Agency database (34) and ond analysis with baseline set at the second examination. our main objective in this Swedish cohort study quency categories in increasing order from zero times per was to determine whether fruit and vegetable intake or total month to more than 3 times per day. We used the under- vegetables (carrots. onion. we took into account ab- sorption (6% for coffee and 4% for tea) when calculating the Exposures ORAC (36). cabbage. Hoffmann-La Roche AG. cauliflower. The participants reported. In accordance with national dietary guidelines (32). antioxidant intake modifies the previously observed rela. Despite a response rate of only 49%.714 women who were alive on January 1. peas. Instructions in the FFQ stated that 1 serving of milk years residing in 2 Swedish counties completed a question. and other fruit). ation between the FFQ and four 7-day food records every All men aged 45–79 years residing in 2 counties in central third month (a gold standard reference) was approximately Sweden were invited to participate in the study (n = 100. Missing values for individual dairy products were inter- quent expanded questionnaire was sent to the 56. or high-fat (3%)). were fewer. FFQ contained 31 items with available ORAC values. The to- 45. 5 fruits (apples. broccoli. In a sec. and other vegetables) (29–31). independent of the amount in- 1987–1990 when 74% of all 90. orange juice. Basel. ity registered between baseline and September 30. porting of dietary intake (28). 26). In the 1987–1990 FFQ. but they comprised more fruit or vegetable items in each category. Spearman coefficients for correlation between the The FFQ and lifestyle questionnaire was completed by FFQ and the averages of these four 7-day dietary records 48. the Spearman coefficient for correl- The Cohort of Swedish Men was established in 1997. consumption of milk and of fruits lettuce. medium-fat (1. According to validation studies of the self- and free of any previous cancers. including milk (ei- ther low-fat (≤0. 25.5%). The fruit and vegetable categories repre- METHODS sented the typical consumption pattern in Sweden at the time of each investigation. the Co. which were regarded as women with implausible values for total energy intake (≥3 zero consumption. The 861 kcal/day and 7. as the sum of the antioxidant content of the 31 food items. berries. in oranges/citrus fruit. 0. We calculated estimates of total antioxidant capacity from and prevalence of overweight (29). The correlation between the total antioxidant capacities of dietary ORAC and plasma ORAC was 0. a subse. and intakes were summed into a sin- lifestyle that had been enclosed with a mailed invitation to gle measure representing total milk intake on a continuous undergo routine mammography screening. spinach. yogurt. For the present analysis.240 women without a prevalent cancer sumption frequency of each food item by the nutrient con- diagnosis in the SMC with information from 1987–1990 and tent of age-specific portion sizes and reference data obtained 38. compensates for overall under.7 (35). beet root. Sweden. this age range in relation to age distribution.311 kcal/day). is unlikely to represent a bias for the ob- standard deviations below or above the log-transformed mean served findings (33). cutoffs were 574 kcal/day and 4.303). consumption. only based cohort studies. peppers. In fact. corresponds to 1 glass of 200 mL. we were adjusted for total energy intake using the residual included 36. pea soup. 1998. time. the numbers of fruit (n = 4) and vegetable (n = 5) categories tionship between milk consumption and death. scale.707 kcal/day) milk consumption on the FFQ part of the questionnaire re- (27) and those with missing data on all items regarding fruit ported that they did not consume milk when posed a specific and vegetable consumption.5%). and free of tal antioxidant capacity of the diet (µmol/day) was calculated previous cancers were available. educational level. reported milk intakes.8% had consumption of less than 1 glass/day intake. In the present study. been shown to be poorly absorbed. cheese. 1998. of death. The SMC started in the calculation of daily intake. by means of a valid and reprodu- cible FFQ. In 1997. bananas. In Scandinavia. Nutrient intakes were estimated by multiplying the con- ysis included 61.850 men. Exclusion of outliers for energy question. SMC data set. toes. lying cause of death from the Swedish Cause of Death . their average frequency of consumption of up to 96 Outcomes foods and beverages during the past year.331 women with updated information from 1997. as described in detail previously (18).280 men who were alive on January 1. The studies have been approved by the Regional Switzerland).or overre. We excluded tion of missing data for single items.303 women aged 39–74 gested. 92% of those who did not report energy intake. a first anal. the Swedish Mammography Cohort 1 glass of juice (fresh or from concentrate) was included in (SMC) and the Cohort of Swedish Men. toma- and vegetables displays a wide range in intake (1. in addition to adjustment for total energy intake in the according to complementary open questions regarding dairy statistical analyses.4 and 0.31. The small frac- still living in the study area (response rate 70%).2 Michaëlsson et al. garlic. The single FFQ administered in 1997 was used to simplify calculated by multiplying the average daily consumption of the comparison between men and women. We excluded men with diet analyzed with an oxygen radical absorbance capacity implausible values for total energy intake (cutoffs were (ORAC) assay.7 for individual fruit and vege- hort of Swedish Men is representative of Swedish men in table items. Milk intake was specified naire covering diet (food frequency questionnaire (FFQ)) and according to fat content. There were 8 possible fre- Therefore.

8 (19.5) 191.8 (1.0 (4.685) 1.7) 55.385 38. g/day 19.Table 1.9 (3.59) Milk.9 (1.6) 85.6 (60.61) 1.900 31.2) 4.06) Dietary intake Energy.2 5.5 (67.3) 97.301 14.8 2.0 (12.414 (433) 1.1) 21.581 9.2) 75. of Mean (SD) % Mean (SD) % Mean (SD) % Mean (SD) % Persons Persons Persons Persons All participants 16.3 7.2 (9.1 (8.8 (5.4) 196.240) Milk Intake.3) 4.8 (9.8 (40.8) 42.64) 1.5) 54. glasses/day <1 1–<2 2–<3 ≥3 Characteristic No.537 (413) 1.6 (14.70) 1.3 (37. g/day 62.0) Leisure-time physical activity.0) 69. Antioxidant Foods.09 (0.0 (18.1 Table continues 3 . hours/weekc <1 3.031) 201.1 (3.8) 81.9 1.0 (8.9) Fruit and vegetables.1 2.8) 25.1) Cheese.6 (3.8 509 9.8 (21.06) 1.9) 400.5 (1.1 (4.8) 27.4 (3.587 (204) Retinol.7 (22. mg/day 0.7) 54. years 53.5 (9.9 783 14.7 (63.2 15.0 (143.8 1.8 2.2 6.7 (63.256 19. mg/day 1.1 (1.8) 42. m (n = 59.094 26.869 27.954 25.8 (151.1 3.0) 2.2) Saturated fat.94 (0.101 (174) Vitamin D.423 14.3 (19.1 Age at entry.0 (147.4 (105.2 (2.1) Vegetables.4) 5.9 (8. Characteristics of the Swedish Mammography Cohort (Women) According to Milk Consumption at the 1987–1990 Baseline (n = 61.64 (0.8) Protein.4 (2. MET-hours/day 42. g/day 70. g/day (n = 61.2 (113.350 8.526 32.0 >5 1.077 19. g/day (n = 61.0) 24.4 (8. of No.405 25.8 (101.104) 92.5 23.0) 1.1) Red and processed meat.3 (9.8 1.2) 73.9) 24.3 (17. μg/day 3.960) 24.0 (9. g/day 102.783 31.3 1 4.2) Height.8) Total fat.2 (6. and Mortality Alcohol.9 4–5 2.6 2–3 5.1) 3.64 (0.0 (24.3) 201.2 (4.4 (8. g/day 26.7) Phosphorus.9 (4.282 31.2) 85.7 (117.0) 676.9) 52.242 (184) 1.2) 26.6) Calcium. of No.9) Yogurt.0) 24.0) 48.06) 1.64 (0.5) 87.7) 183.4 3. of No.2 4.286 14.6 (132.7 (3.0) 3.03 (0.6 (4.396 18.4 (4.429 25. mg/day 733 (159) 859 (139) 972 (144) 1. kcal/day 1.1) 30.478 (174) 1.6 (2.900 18.06) 1.9 (16.254 25.8) 79.083 8. g/day 44.6) Body mass indexa (n = 58.1) 87.5 (39.967 (525) Milk.2) 93.4) 65.0) Fruit.9) 3.0) c Physical activity. g/day 3.1) 66.4 (1.3 4.09 (0.8) 42.7 1.6) 26.6 (136.5) 2. g/dayb 17.709 (433) 1. servings/day 3.4 (44.654 9.365 (165) 1.1 (9.2 (42.64 (0.

1 4.057 4.6 Charlson comorbidity indexe 0 15.450 28.595 46.6 3. glasses/day <1 1–<2 2–<3 ≥3 Characteristic No.3 1.2 c Ever use of estrogen replacement therapy 3.7 3. SD.1 1.840 16.3 13.206 48.7 10–12 1.700 28.9 1 1. 4 Michaëlsson et al. Each condition is assigned a score of 1–6.3 1.9 12.430 25. c Values were imputed from the 1997 questionnaire. of Mean (SD) % Mean (SD) % Mean (SD) % Mean (SD) % Persons Persons Persons Persons Education.0 1.340 24.9 483 2. a Weight (kg)/height (m)2.231 8.0 528 9.8 21.864 8.458 26.1 2.7 1. d Such as vocational education.4 2.5 733 4.791 7. .7 5.393 78.7 3.508 22.0 Living alone 3.8 403 7.0 801 14.5 6.5 ≥2 325 1.9 1. years ≤9 13. of No.1 1. of No.914 17.0 1.3 3.3 7.111 90.348 24.6 Current use of calcium-containing supplements 2.3 3.221 52.371 8.1 266 4.5 Current smoker 3.292 22. Table 1.6 12. Continued Milk Intake. The Charlson comorbidity index predicts mortality for a patient who may have a range of up to 17 comorbid conditions. Ninth.4 4.676 79.235 78.318 31.8 256 4.495 20. b 1 g/day of milk ≈ 1 mL/day.9 632 4. depending on the risk of dying associated with the condition.895 25.146 4.3 1.143 89.487 81.646 29. of No.8 Otherd 1.699 7.939 23.345 19.8 1.1 Ever use of cortisonec 897 5.1 357 2.0 519 9. and Tenth revisions) diagnosis codes were collated from the National Patient Registry to calculate weighted Charlson comorbidity scores.159 14.085 20.2 >12 897 5. standard deviation.3 146 2.4 (regular or occasional)c Ever use of antioxidant-containing supplementsc 5.6 Abbreviations: MET.366 8.401 8.054 6.3 Smoking statusc Never smoker 8. e International Classification of Diseases (Eighth.063 21.5 18.3 1.3 1.870 51.907 87.5 Former smoker 5.817 89.8 4. metabolic equivalent.027 29.7 4.3 1.8 6.289 18.4 5.232 8.741 24.875 29.

1) 908.0) 276.9 (6.2) 63.5 (10.3) 3.1) Height.9 658 1.4 (135.8) 5.8 (50.3 (51.3 228 12.3 (250.65 (0.1) 27. g/day 60.7 (152.65 (0.7 >5 2.7 (5. g/day 49.1) 63.2) 213.9 231 12.6 (51.1 (6.9 (3.3 4–5 2.7 2.5) 2. g/day (n = 36.6 (141.0 (1.773 11. g/day 173. servings/day 5.49) Alcohol.0 (65.321) 42.045 33.5) 5.9) 223.0 703 10.0 (2.157 5.8 (7. kcal/day 1.157 (268) 1. g/day 63. of Mean (SD) % Mean (SD) % Mean (SD) % Mean (SD) % Persons Persons Persons Persons All participants 26.86 (0.450) 227.5 (5.617 72.282 19.841 (5. of No.4) Leisure-time physical activity.3 (4.2 (34. μg/day 4. Characteristics of the Swedish Mammography Cohort (Women) According to Milk Consumption at the 1997 Baseline (n = 36. m (n = 36.4 (4.6) 277.73) 0.6 797 12.2 (4.0) 25.00 (0.3) 218.8) Saturated fat.633 11.2) Physical activity.7) 42.7 (46.729 24.4 (144. 12.2) 56.06) 1.8 (45.714) Milk Intake.9) 5.8 2.4 (3.Table 2.9 (1.4) 68.6 (5.06) Dietary intake Energy.0 1 5.98 (0.2 (9.9 (149.106) 13.1 (10.3 (409.676 (504) 1.6) Calcium.3 (1.220 34.2 86 15.030) 13.551) 1.8 (11.4) 3.65 (0.1) 70.488 (210) 1.3 635 33.865) µmol/day Red and processed meat. of No.6 (60.1 (6.5) 59.6) 4.7 428 22.7 2–3 8.0) Protein.0) 208.6 116 20.3 (40.827 (521) 2.8 375 19.5 (148. years 61.4) 59.8) 58.618 (383) Vitamin D.4) 27. Antioxidant Foods.6) Cheese.64 (0.6 1.076) 24.0) 50.6 (4.628) 219.8 118 21. mg/day 0.8) 211.6) Fruit and vegetables. hours/week (n = 32.687 19. glasses/day <1 1–<2 2<3 3 Characteristic No.8) 42.3 (11.3) 26.5 170 30.0 (9.8) 209.2 (3.356 (211) 1.8) Phosphorus.4 (37. g/day 4. and Mortality Retinol.8 Age at entry.9 (176.374 (5.8) 182. mg/day 977 (270) 1.005 (561) 2.8) Yogurt.0) 67.2) 81.225 (5. g/dayb 75. of No.2 (9. MET-hours/day (n = 28.6) 55.4 (9.1) Oxygen radical absorbance capacity.4) 195.95 (0.1 (9.5 7.0 1.0) 5.8 (155.1 (2.5 (11.9 (4.4 (4.581 (219) 1.0 71 12.4 (1.2 (10.06) 1.5) 6.68) 0.3 (6.8) Fruit.271 (651) Milk.3) 63.297 (288) 1.73) 1.7 (194.3 Table continues 5 .06) 1.800 (280) Milk.469 22.9) Total fat.1 (209. g/day 69.5) Body mass indexa (n = 36.254) 13.7 (307.6 (42.2) Vegetables.2 (11. μg/day 1.803 (5. g/day 27.799) <1 4.0) 75.0) 42.9) 25.285 19.8 (4.4) 465.2) 25. g/day (n = 36.4) 72.

910 19.2 10 0. f High cholesterol or ever use of statins.5 Current use of calcium-containing 6.294 19.7 ≥20 pack-years 2.8 supplements Ever use of aspirin 11.2 1.5 906 42.764 44.9 1.7 216 32. of No.6 196 9. e International Classification of Diseases (Eighth.0 6.8 277 13.465 24.9 5.133 8.064 23. SD.1 771 35.691 23.174 43.2 3.4 10–12 2.495 43.8 43 6. of Mean (SD) % Mean (SD) % Mean (SD) % Mean (SD) % Persons Persons Persons Persons Education.5 150 23.9 Abbreviations: MET.9 324 4.804 52.8 Ever use of estrogen replacement therapy 12.035 14.1 52 7.2 504 23.929 7.2 ≥2 1.126 71.5 2 0.6 81 3.3 395 18. c Such as vocational education.2 333 51. of No.8 529 24. The Charlson comorbidity index predicts mortality for a patient who may have a range of up to 17 comorbid conditions.0 268 12.1 1.6 >12 5.3 Smoking status (n = 36. metabolic equivalent.163 8.0 <20 pack-yearsd 4.182) Never smoker 13.2 Former smoker 6.2 16 0.3 Ever hypercholesterolemiaf 9. Ninth.1 Charlson comorbidity indexe 0 23.580 21. .683) ≤9 19. Milk Intake. b 1 g/day of milk ≈ 1 mL/day.2 219 10.298 participants.132 43.759 79.5 160 24.4 81 3.3 50 7. a Weight (kg)/height (m)2.1 ≥20 pack-years 1.662 23.4 123 18.384 19.0 1.460 9. of No.0 886 12.1 288 43.328 13.4 115 5.4 1.069 4.3 1.1 668 9.3 168 25. Each condition is assigned a score of 1–6.520 35.2 255 3.0 960 44.6 930 43.6 297 14.2 1.7 Otherc 40 0. depending on the risk of dying associated with the condition.0 465 6.857 86.3 supplements (regular or occasional) Ever use of antioxidant-containing 11.7 4.157 54.2 1 2.2 74 11.6 1. Continued 6 Michaëlsson et al.348 24. standard deviation.440 47.8 2.1 541 82.4 172 26.290 86.2 550 7.2 1.1 Current smoker 6.1 583 27.038 3.5 3.8 <20 pack-years 3.9 26 4. years (n = 36.115 43.416 88.5 Ever use of cortisone 1.134 57. d Information on pack-years of smoking was available for 35.038 14.5 285 43.735 23.2 3. and Tenth revisions) diagnosis codes were collated from the National Patient Registry to calculate weighted Charlson comorbidity scores.Table 2.6 Living alone 5.6 700 10.9 86 13.7 313 48. glasses/day <1 1–<2 2<3 3 Characteristic No.8 483 73.3 115 18.3 74 11.699 37.2 311 14.721 79.

μg/day 6.6 (286.8) Physical activity.1) 177.3) 25.77 (0.0) Calcium.110) 184.2 (9.9 1.7 (68. Antioxidant Foods.4) 26.1 1.592 14.6 (15.9) 75. g/day (n = 45.8) 103.9 2–3 5.8) 102.988 22.3 (14.9 (2.0) 42.387 (350) Milk.74) Alcohol.5 (9.3 (15.7 (2.2) 185.940 20.3 (14.127 32.295 19.4 1. g/day 40. mg/day 1.247 (386) 1. kcal/day 2.77 (0.975) 25. servings/day 4.6 (9. g/day (n = 40. g/day 181.1 (140.078 17.8) 60.8 (137.691 31.6 1 3. Characteristics of the Cohort of Swedish Men (Men) According to Milk Consumption at the 1997 Baseline (n = 45.9 7.5 6.0 (118.640 (386) 1.0 (10.064 30.1 (13.9) 61.9) 7.4 1.1) 41.7 4–5 2.0 (2.9) 89.5 10.6) 89.6) 173.2 2.71) 1.2 (2.3) Oxygen radical absorbance capacity.07) 1.8 (66.3 (63.3) Vegetables.563) 15.8 Table continues 7 .1 (3.749 (798) 3. hours/week (n = 40.2) 25.0) 181.2 Age at entry.7 1.0 (22. mg/day 1.0 1.874 15.5 (59.3) Leisure-time physical activity. glasses/day <1 1–<2 2–<3 ≥3 Characteristic No. years 59.9 (63. g/day 72.376) 14.740 (5.3 (5.7) Fruit and vegetables.1) Total fat.792 29. g/dayb 64.3 (59.4) Yogurt. of Mean (SD) % Mean (SD) % Mean (SD) % Mean (SD) % Persons Persons Persons Persons All participants 20.1 (131.129 (914) Milk.9 (245.0 (57.812) 41.450 (370) 1.Table 3.19 (0.0 1.9 953 15.5 (133.5 3.470 19. g/day 101.3 (9.4 (3.9 999 14.7) 85.1 (372.6) 13. m (n = 43.354) 14.2 1.0) 6.3) 267. MET-hours/day (n = 34.190) 1.2 (2.8 (59.0) 111.35 (0.218 (5.6) 165.4 (237.3) 162.6) Height.7 (222.547 15.7) 14.9 876 13.28 (0.144 44.9) 7.6 (54.8 (5.5) 4.3) 909. g/day (n = 44. g/day 98.5) 42.803 23.5) Body mass indexa (n = 42. of No. mg/day 1.7 (17.2) 108.07) 1.0 (15.493) 17.96) 1.845 19.2 (4.452 21.4) 3.4) Protein.6 (3.1 (18.9 (3.8 1.0) Phosphorus.922 (294) 2.0) 173.315 12.7 (2.6) 182.8) Cheese.1 728 12.4) 3.4 (14.153 (5. 14.77 (0.3 (49.459 16.6) Saturated fat.5) 89. of No.5 (118.85) 1.945 (483) Vitamin D.2 (125.256 12.8) 41.496) <1 3.2 (123.511 (789) 2.8) 41.4) 467.9) 13.1 (9.5) 40.07) Dietary intake Energy.77 (0.7 (3.185 (292) 2.063 (282) 2.870) 182.25 (0. and Mortality Retinol.6) 61.1 >5 2.280) Milk Intake.583 (772) 2.834 (5.2 (26.2 (14.708) µmol/day Red and processed meat.5 (4.488 24.1 (9.8) 70. of No.8 (61.7) 102.07) 1. g/day 89.2 (9.9) 105.3) 163.1) Fruit.6 (3.

151 15.978 28.954 26.188 18.8 Ever use of cortisone 843 4. Continued 8 Michaëlsson et al.9 2.786 24.1 837 12.376 20.488 36.4 1.9 1.072 65.5 394 5.585 33.021 13. glasses/day <1 1–<2 2–<3 ≥3 Characteristic No. d Information on pack-years of smoking was available for 42.381 23.3 369 5.7 1.9 710 10.6 <20 pack-yearsd 4.277 12. The Charlson comorbidity index predicts mortality for a patient who may have a range of up to 17 comorbid conditions.2 ≥20 pack-years 2.317 16.397 32.437 69.4 >12 3. Milk Intake.2 1.2 883 11.5 4.599 13.221 43.1 1.718 36.1 5.2 884 11.1 7.0 ≥20 pack-years 2.2 309 4.7 1.352 13.8 2. Ninth.395 31.0 900 14.912 14. b 1 g/day of milk ≈ 1 mL/day.7 Otherc 80 0.0 5.3 653 10.8 1.255 32.9 5.656 14.027 14.7 800 11. .182 82.5 2.2 712 10.2 ≥2 890 4.145 45.3 1.028 37. of No.250 30. e International Classification of Diseases (Eighth.1 310 4.7 3.500 32.6 Living alone 3.Table 3.0 2.3 3.8 Ever hypercholesterolemiaf 8.4 1.337 21.6 2.3 2.8 838 12.704 43.5 1. SD.892 82.5 1.775 18.3 6.0 4. of Mean (SD) % Mean (SD) % Mean (SD) % Mean (SD) % Persons Persons Persons Persons Education.129) ≤9 13. c Such as vocational education.2 3. and Tenth revisions) diagnosis codes were collated from the National Patient Registry to calculate weighted Charlson comorbidity scores. standard deviation.259 participants.3 933 9.4 Smoking status (n = 44.8 1.6 <20 pack-years 1. years (n = 45. metabolic equivalent.011 29.5 Abbreviations: MET.308 77.5 10–12 3. a Weight (kg)/height (m)2.7 1. of No.7 2.3 30 0.4 23 0.9 1.526 14.1 2.102 84.763 9.967 44.191 41.8 Former smoker 8.1 976 13.764 16. depending on the risk of dying associated with the condition.4 46 0.4 597 5.502 74.694 36.2 449 4.6 895 13.535 22.884 25. Each condition is assigned a score of 1–6.380 31.526 14.9 8.1 Current smoker 4.152 10.8 supplements Ever use of aspirin 6.6 1.2 2.6 1.152 38.2 supplements (regular or occasional) Ever use of antioxidant-containing 6.6 2.858) Never smoker 6.0 4.301 33.539 23.5 3. f High cholesterol or ever use of statins.4 1 2.831 16.4 Current use of calcium-containing 2.996 35.311 17.667 82.314 12. of No.0 Charlson comorbidity indexe 0 17.

retinol. energy intake. >12 years. 2–<3. codes I00–I99) and cancer (International Classification of Diseases. and phosphorus. whichever came first. and. 1990) (solid line). fruit and vegetable intake. among women. smoking 0. or current smoker and.000 20. marital status (living therapy. or ≥3 glasses/day) and categories of fruit and vegetable intake or quartiles of ORAC. 2–<3.000 40. current with <20 pack-years. body mass index (weight (kg)/ rated fat. glasses/day evaluated trends in mortality rates according to milk intake. One glass of milk corre- sponds to 200 mL.4 To select suitable covariates for the multivariable model. C) 1.8 (<1. intakes of yogurt. 4–<5. we used present knowledge and directed acyclic graphs 0 5 10 15 20 (38). Antioxidant Foods. and in the fourth model. total en. The proportional hazards assumptions were confirmed graphically by log-log plots. smok- Measures of interaction were calculated on the basis of ing habits (never.9 Adjusted Hazard Ratio ever use of antioxidant supplements (yes/no). or current with 0. educational level (≤9 years.. We calculated age-adjusted death rates and age. 0 2 4 6 or the end of the study period. oxygen radical absorbance capacity (ORAC. We categorized fruit and vegetable intake as <1.0 codes from the International Classification of Diseases. fruit and vegetable intake (B). we additionally adjusted our estimates for Cohort of Swedish Men (baseline 1998) (long-dashed line).000 putation (41). smoking status and physical activity) (1). the date of emigration. height. for baseline 1997. 0. The shaded energy-adjusted dietary intakes of protein. Tenth Revision.and multivariable-adjusted hazard ratios Adjusted Hazard Ratio and 95% confidence intervals for categories of milk intake 0. C-codes) through Adjusted Hazard Ratio December 31.0 entry until the date of each outcome. persons the relationship of milk intake (A). Fruit and Vegetable Intake. and Mortality 9 Registry to define secondary outcomes: mortality from cardio. and current smok. Ninth Revision. We also imputed covariates not assessed at Oxygen Radical Absorbance Capacity. To our second model. Associations with less than 1 glass of milk and 5 or more servings of fruit milk intake were further adjusted for intake of fruit and vegetables. Milk. and and vegetables per day as the reference category for the associations with fruit and vegetable intake and ORAC were adjusted following groups (annotations in parentheses): milk intake for intake of milk. or other). 1. use of cortisone. calcium. 1–<2. The model for the total effect included age. body mass index (weight (kg)/height (m)2). for baseline 1997. µmol/day the baseline of the SMC in 1987–1990 (e. A) 2. using persons consuming pack-years of smoking).5 Statistical analysis We calculated time at risk for each participant from study 1.8 status (never. 1–<2.5 missing data on covariates were imputed using multiple im- 0 10. also adjusted hazard ratios (HRs). 0. 1. alone vs. alcohol intake. B) spline Cox regression with 3 knots placed at percentiles 10. Additional sensitivity analyses in. total and satu. 40).7 ≥20 pack-years) and Charlson’s comorbidity index (pos- sible range of scores. with the latter category reflecting dietary recommendations (32). and red and processed meat.g. height. .000 30. ever use of antioxidant-containing supple- ments. 2014. not). intakes of yogurt. 10–12 years.0 and alcohol (all continuous).0 50. Tenth Revision. We first Milk Intake. former with <20 pack-years. baseline 1987– of calcium-containing supplements and.5 vascular diseases (International Classification of Diseases. physical activ- ity (metabolic equivalent-hours/day.6 or ≥5 servings/day. In a quency questionnaire (baseline 1997) (short-dashed line). 0. hormone replacement cheese. servings/day ergy intake. physical activity (metabolic equivalent-hours/day). cheese. in the SMC after administration of the second food fre- use of aspirin and prevalent hypercholesterolemia. and weighted Charlson’s comorbidity index. ever height (m)2). and with a body mass index greater than 35. and 90 of the exposures (37). 3–<4. we used corresponding 2. Sex-specific multivariable-adjusted spline curves illustrating cluded exclusion of the first 2 years of follow-up. To avoid 0. former. living alone (yes/no). For 1987–1996. vitamin D. education. areas illustrate 95% confidence intervals. and ORAC using restricted cubic. continuous).6 loss of efficiency and limit the introduction of bias by re- stricting the analysis to persons with complete data alone. 0–33. continuous) (39. Figure 1. former with ≥20 pack-years. red and processed meat. we also added as covariates use ratios for death from all causes by the use of time-updated information in the whole Swedish Mammography Cohort (SMC. µmol/day) (C) with hazard ers. 0. Covariates were age.

6 16.0 16. Baseline 1997d ORAC quartile 1 20.8 20.6 19.3.264 62.316 6. 18.8 373 1.1 15.2 20. 21.0 19.1 11.4 20.0 29 52 40. 34.711 6.5 24. 24.1 634 1.2.7.6. Baseline 1997 Fruit/vegetable intake.3 776 42. 18.9 2.1 16. 31. 18.2 27.627 17.300 28.836 17.8 416 16.434 4. servings/day <1 32. Swedish Mammography Cohort (Women).6.3 16.6.5.1.7 24.597 Swedish Mammography Cohort (Women).4 21.4.1. 29. of PY at Total 95% CI 95% CI 95% CI 95% CI Rate Cases Risk No.0 698 1.298 6.7 92 160 41.5 16.127 21.1.3.1 76 157 2 17. 21.2 197 627 19. 22.4 24.4 16.030 3. 29.7 2.6 66 171 29.8.541 23.1 13.9 4.644 13.0 191 331 32. Fruit and Vegetable Intake.9 520 1.3 21. 18.7. of PY at Total Mortality No. 16.776 15. 20.9.2 284 909 18.843 19. 27.1 18.2 1.4 113 296 ≥5 16.100 24.9.1.6.5.2 22.9. 21.7 624 1.2 159 508 19. 29.9.9 16. Rate Cases Risk No. Table 4.5 15.5 213 8.5 28.6 23.9 51 161 4 15.000 Person-Years at Risk.291 10.4 2.5 20.1. 16.b Rate Cases Risk No.754 6.0.3 25.0 734 47.6 16.8. of PY at Total Mortality No. 1987–2015a Milk Intake. 21.2 19. 12. 23. 32.389 282.3.827 12. 27. 60.622 6.0.125 21.0.8 202 467 27.6.729 19.6 25.975 18.0 15.9 488 1.1.0.6 926 3.5 19.7 423 15.4 1. 13.9 20.065 2–<5 14.773 ≥5 20. 72. 16. 37. of PY at Total Mortality No.2 438 1.6 29 51 2–<5 18.4 2.3.1 23.3 18.371 17. 43. 23.4.9.4 509 20.9 21. 20.1 219 413 32.116 283. 15. 38.133 2–<5 21. 20.873 17.336 27.7 20.5. 21.0 63 205 Table continues .667 17.108 15.5 79 291 Cohort of Swedish Men.2 19. 22.1 227 399 32. 14. Baseline 1997 Fruit/vegetable intake.1 1.0 14.5 538 1.0.498 21.424 1–<2 17.269 18. 24.979 23.0.8 28. 25.8.5 25. 18.8 3. 36. According to Milk Consumption.7 571 1.4.7 14. 30.7 1.7 1.3.4. servings/day <1 27.3 15.325 21.2.931 22.277 11.2 240 528 21.9 22. glasses/day <1 1–<2 2–<3 ≥3 Mortality No.8.1 15.458 28.8.6.4 19.2 17.0 1. Baseline 1987–1990 (Time-Updated Analysesc) Fruit/vegetable intake.6 2. 24.087 5. 24.3.5 890 2.511 Swedish Mammography Cohort (Women).759 21.2.850 22.8 15.3. 28.3 12.097 26.0.8 16. Rate Cases Risk No.257 143.7.4.4. 20.8 2.0.8 17.8 18. 25.7. 19.9.8 29. 17.5 19.057 19. 18.107 19. 23.1 228 457 1–<2 25.158 19.827 18.0 21. and Quartile of Oxygen Radical Absorbance Capacity.8.025 23.889 22. 25. 27.168 149. 10 Michaëlsson et al. 31. 23.4 247 16.3 383 774 32.2 812 56.0 15.1 14.354 26.0 1.6 27.5 4.705 25.0. 18.7 1.4. 37. 24.2 971 53.2.124 3.8 43 135 3 16.0 17.5 15. 23.3. servings/day <1 22. Age-Standardized Rates of Mortality in the Swedish Mammography Cohort (Women) and the Cohort of Swedish Men (Men) per 1.815 ≥5 12.1. 28.3 194 555 22.4 17.312 3.0. 22.2 310 17.627 23.8 560 1.2 3.786 218.7.9.0 1.6 586 1.7 23.0 12 20 1–<2 21. 24. 40.7. 26.6 18.

7 27. Baseline 1997e ORAC quartile 1 25. 25.Table 4.4 23. 23.4 1.1 833 1.967 µmol/day. 15. Rate Cases Risk No. oxygen radical absorbance capacity. 21.809 22.3 19. 27.517 26.180 5.9 710 1. 7. ORAC. Antioxidant Foods.1 1.1 943 2.1.617 5.785 20.001 Abbreviations: CI. PY. 22.3 20.3.3.2 20.477 µmol/day.6 20. 24. 25.6 20. of PY at Total Mortality No. confidence interval. person-years.508 2 21.880–<13. of PY at Total 95% CI 95% CI 95% CI 95% CI Rate Cases Risk No.2 610 1.664 3 20.160 4.4.217–<15. 30. Continued Milk Intake. 10. 20.645 24.418 µmol/day.0 659 1.4. 32. of PY at Total Mortality No.488 µmol/day). quartile 4 (≥17.7.4 625 1. b Total number of participants in category.1 24.892 µmol/day.731 29.2 2. 13. Milk. quartile 2 (10. c Because of the time-updated exposures.7 25. 23.2. Cohort of Swedish Men.457 µmol/day). Rate Cases Risk No.488 µmol/day). 22.880 µmol/day).1 865 2.1 22.967 23. d Median ORAC value: quartile 1 (<9.546 µmol/day). 12.7.490 µmol/day. 26.3 1.9 18. 18.9 19. 24. 21. quartile 3 (12.6 947 2.8.546–<12.457 µmol/day).9 1.1.9 648 2.2. of PY at Total Mortality No. Follow-up ended on September 30.8 20. 28.217 µmol/day).6.154 21.564 28. 8. and Mortality 11 .361 4. person-years at risk are given. a Baseline dates varied by cohort and analysis.701 4 19.1 21.b Rate Cases Risk No.914 µmol/day.2 21.1 26.2.904 23.331 µmol/day.567 21.160 2. quartile 4 (≥15.881 µmol/day).2.653 µmol/day.857 25. quartile 2 (9.906 22. glasses/day <1 1–<2 2–<3 ≥3 Mortality No.2 566 1. 2015. 23.7 594 1. quartile 3 (13.881–<17.3. e Median ORAC value: quartile 1 (<10.4.

marital status (living alone vs. using persons with the lowest milk in- contrast. and milk intake ≥3 glasses/day. B) HRs based milk. 1. and death rates decreased with high.03 1.11. body mass index (weight (kg)/ and the highest intake of fruit and vegetables (≥5 servings/ height (m)2).03 (2.46) (1.99. The shading corresponds to the value of the tios for mortality by milk and fruit/vegetable intake or ORAC.21. 1.07.25 1.08) (0.53) (0. fruit and vegetable intake ≥5 servings/day A) (HR10).000 bootstrap samples. 2.13.0) at baseline and 5. 2−4.22−1.28 1. in both men and women. 1.82) RESULTS <1 1−1.9 ≥3 combination category. 1.04 2.1 servings/day (1.08. 1. we combined milk intake with fruit and (reference) (0.31 consumption (Figure 1A).3 servings/day (SD.33) The statistical analyses were performed with Stata 13. 2.9 2−2.88.1 (StataCorp LP.96. physical activity (metabolic equivalent-hours/day). also sumption in every category of fruit and vegetable intake or pack-years of smoking).60 (reference) (1. education.09 1. smok- tios for mortality tended to increase with higher milk con.88.43) (1.17.35) (1.14 (0. fruit and vegetable intake Fruit and Vegetable Intake.17) (1. . whereas in 1997 only 2% reported such intake <1 1. intakes of yogurt.14. 1998. Men had on average higher consumption of milk. 1. death rates were already increased at 1–2 glasses of milk per day. From January 1.41 1. milk intake <1 glass/day.12.83 2.000 µmol ORAC/day). ≥5 1.17) (1. 1.02 1.67. glasses/day (581. Texas).94 (1.9 1. Death rates increased in both sexes with increasing milk 1. glasses/day Characteristics of the study population by baseline date and sex are presented in Tables 1–3.00 1. and weighted Charlson’s comorbidity index. 1.72.73. women and men who reported high consumption of fruits and A) HRs based on time-updated information on the whole Swedish Mam- vegetables or had high ORACs combined with low intake of mography Cohort (SMC) (women.10 (reference) (0.04.23) 15.10 1.39 1.391 women (total time at risk = 1.54) (1.97. 2−4.24 1.42−2.92.78 2.688 person-years) died during a mean follow-up period of 15 years (maximum 17 C) Fruit and Vegetable Intake. and red and processed meat. Hazard ra. 1.16 1. day) or ORAC (highest quartile) as the reference. 1.9 ≥3 Milk Intake. servings/day 1990 (Table 1).01.76.03−3. servings/day <1 serving/day (HR01). College Station.0) at the follow-up examination.11) (0. ever use of antioxidant-containing supple- ORAC. 15% drank ≥3 glasses/day in 1997 (Table 3). 1. we present age-adjusted rates and numbers of deaths by each <1 1−1.82 (1.02) 1.35 1.14 (1. 2. One glass of milk corre- using the group with the lowest intake of milk (<1 glass/day) sponds to 200 mL. Men (men.434. 10. cheese.51) er consumption of fruit and vegetables (Figure 1B).04. 1.5).91) (1. although a threshold seemed 1.14) (1.13) (0.51) (1.32 1.01. In women. ≥5 1. 1. 1. the darker the shading.12 1. 1.9 1. <1 (1.05 1.18 1.54) (1. 1.14.43 1. <1 1−1. alcohol intake. The rate of mortality was highest Milk Intake. 1. 1. 1. or current smoker and.18) vegetable consumption.07. height. although the estimates were attenuated with increasing ments.97. on the SMC after administration of the second food frequency question- naire (women. 1.56) (SD. 1. and (1. servings/day years).171 person. baseline 1997). <1 1. 1.21) (1. 1. 1.16) (1.42) (1. 1.13) 3.00 1.34 1.13) (0. former.32.35 1. higher death rates started to be observed after only 3 or more glasses of milk per day 2−4.24) (1.25.06 1.99.22) (2. ≥3 glasses/day. as well as with ORACs. 1. 2. Approximately 9% of the B) women reported milk consumption of ≥3 glasses/day in 1987– Fruit and Vegetable Intake. 1. 2.23) (Figure 1A).29 Men reported an average consumption of 4. as well as with higher ORACs (Figure 1C).97.11) (0.9 to be discerned (>5 servings of fruit/vegetables per day and (1.10 1. baseline 1997). 3.97. 1.785 person-years) and 15. The rela- tive excess risk of interaction (interaction on the additive 1.76 2.14.46) (1.9 (1.00. onward.06.23 1. 3.26) (1.00 1. In Table 4. 22.43) (1.27 1−1. Covariates were age. In (in parentheses) for all-cause mortality according to combined intakes of milk and fruit and vegetables. ≥5 1.55) 95% confidence intervals were obtained by means of the bootstrap percentile method with 1.21) fruit and vegetable intake <1 serving/day (HR11).07 In further analyses. 1.63) (1.89−3. In men.9 scale) was calculated as HR11 − HR10 − HR01 + 1 (42). 2. 1.10 1. ing habits (never.40. for baseline 1997. 1. 3. HR.42.12 Michaëlsson et al.9 2−2.39) (0. 1.5 servings/day (standard deviation (SD).9 1.99.38) During a mean follow-up period of 23 years (maximum 29 years). the lowest age-adjusted mortality rates were found in take and the highest fruit and vegetable intake as the reference group.88. Average re. Adjusted hazard ratios (HRs) and 95% confidence intervals with a high consumption of milk. glasses/day among persons consuming less than 1 serving of fruit and vege- tables per day (or in the lowest quartile of ORAC) combined Figure 2.9 2−2. 1. 2.37) 2.11 1−1.24) (0. C) HRs based on the Cohort of Swedish Figures 2 and 3 depict the multivariable-adjusted hazard ra. 2.478 men (687.81 (1.13.94) (1.94) (1. 1. the larger the HR.32) was 3.64.10 1.01 1. energy intake. Intake of fruits and vegetables did not vary by milk intake in either women or men. baseline 1987–1990).61 ported consumption of fruits and vegetables among women 1−1.314 women Milk Intake.96.32.9 ≥3 years) died.06 1.73 1. not).79 (2.20) (Table 2).17) (1.

by different patterns of intake of antioxidant-rich foods in the populations.38).96.30) (1. baseline 1997).22 interaction was discovered among men (data not shown). 46).10 (95% CI: 0. as also indi- cated by our present study.30. a potential explanation for the in- consistent findings may be related to the variability in the range of milk consumption in different populations and.22) (1.07 1.15) (1.29.82). Heterogeneity among studies was observed in most sub- current smoker and pack-years of smoking).16 hazard ratios for cancer mortality were lower (Web Table 5). and with a tal variable (44).98.90.01. 1. and weighted Charlson’s comorbidity index. (reference) (0. 1.40.9 ≥3 eral nutrients common in milk. 1.77. energy intake. the darker the shading. the HR. 1. 1.19 1.42.20 1.21). The total number of cardiovascular dis- B) ease or cancer deaths was less than half that of the number of 1.06 1. 1. 1. available at http://aje.51 1.00 1.94. and current smok- ers (Web Table 8. intakes of yogurt. education. the estimates remained essentially 1.91. consumption of fruits and vegetables or ORAC.10.20) and 1.51) for high consumers of milk with a low 1 1. the larger be evaluated in isolation and have to be interpreted cautiously. Milk.95.41) (1.00.00 1.96.05.88.98.27) in the time-updated analysis of women indicated a modest additive interaction. country.09 4 (reference) (0.10 1.37 (95% CI: 0.33) (1. 1.08 1. 24%–29% of all deaths were excluded) 1.03. 1.94.13. Accordingly. 1.08 1.30) (1.28 (0.org/).43) (1.58) Hazard ratios were not attenuated in women after addi- tional adjustment. One glass of milk corresponds to 200 mL. or (43).19) (1.17) (0.28) Exclusion of the first 2 years of follow-up (Web Table 6. in time-updated likely to ever be implemented. A) HRs based on the Swedish Mammography Cohort after administration of the second interaction for mortality rates between milk consumption and food frequency questionnaire (women.28 deaths from any cause (Web Tables 2 and 3). whereas ORAC Quartile 2 1.98. methodological differences. and study quality (43). smoking habits (never. Antioxidant Foods. 1.05.12 ysis).28 1. 1. baseline 1997). 1. B) HRs based fruit and vegetable consumption was found only in women.30) (0.99. To our knowledge. glasses/day In 2 independent population-based cohorts.73) ORAC intake instead of fruit and vegetable intake as the effect-measure modifier.16) (1.9 2−2.07 1. using persons with the lowest intake of milk and the high. consumption was more pronounced in women. Our postu- sure assessment. the gradient of risk with increasing milk µmol/day). Besides containing supplements.18. the corresponding estimates were 1. 3.42) for cardiovascular mortality (Web Table 4).24) Table 7. 2%–5% of all deaths were excluded.15) (0.27) (0. mortality rates Figure 3.04 1. 1.21) gave estimates similar to those seen in the total cohort.49) (0.07 (95% CI: (1. and red and processed stantial heterogeneity in nonfermented milk consumption meat.11.27) (1.11 1.16) (0. combined high intake of fruit and vegetables.06 1.9 ≥3 DISCUSSION Milk Intake. but serving/day) conferred a multivariable-adjusted hazard ratio of this specific genetic variant is probably weak as an instrumen- 2. and Mortality 13 A) The same comparisons in men revealed a hazard ratio of 1.10) (0. and this study design is un- single exposure assessment.01.15 1. However. respectively. were highest in persons with high consumption of milk com- vals (in parentheses) for all-cause mortality according to combined bined with low consumption of fruits and vegetables or a low daily intake of milk and oxygen radical absorbance capacity (ORAC. including adjustment for vitamin and min- <1 1−1. 1.14) (1. 1. The relative excess risk of interaction estimate 3 (1.05) 0.09.30 1.07 1.31 (95% CI: 1. oxfordjournals. former.00. mortality rates with high milk consumption (1). stress by way of the galactose component of lactose. physical activity among cohort studies in relation to mortality from all causes (metabolic equivalent-hours/day).97.07 1. 1.00 1.11 1. Nevertheless. ever use of antioxidant. 1 (1. 1.22) (0. 1. the hazard ratios remained similar to estimates of all-cause mortality.16) (0. . 1.17) (0.35) of 0. Adjusted hazard ratios (HRs) and 95% confidence inter. 1. depending on the anal- 3 1.22 1. 1. The pattern no randomized trial has examined the association of milk in- was clearer with time-updated information as compared with a take with incidence of mortality. 1. 1.14. body mass index (weight (kg)/height (m)2). 1.18) for high consumers of milk who also consumed 5 or more servings of fruits and vegetables per day.28 1.81 (95% lated mechanism is that milk consumption induces oxidative CI: 1. In women with a single expo. 2% of all deaths were excluded).9 2−2. 1. <1 1−1.99.16.98. A recent attempt to perform a meta-analysis demonstrated sub- alcohol intake. persons with a body mass index greater than 35 (Web (0. 1. 1. glasses/day attenuated in men (see Web Table 1.75) (1. a high intake of milk (≥3 glasses/day) approach might be the use of genetic variation in lactase per- with a concomitant low intake of fruit and vegetables (<1 sistence within a Mendelian randomization study design. No significant 4 1. (0. 1. 1. ORAC.60 (95% CI: 1.02 unaltered.99.02.79 (95% confidence interval (CI): 2. 3. 1.17. with conceivable pleiotropic effects (45.62 fruit and vegetable intake and a hazard ratio of 1. Covariates were age. 2. groups defined by sex. the hazard ratio The present study extends our previous finding of higher was 1. height. not). although they were somewhat Milk Intake. marital status (living alone vs. and an additive est quartile of ORAC as the reference group. 1. Another possible analytical analysis of the SMC. cheese. If we used ORAC Quartile 2 1. 1.08 1. on the Cohort of Swedish Men (men. The shading The findings of our observational investigation should not corresponds to the value of the HR. 1.

A lower female degradation of galactose interaction could have several explanations. forming advanced Mortality rates were increased at more moderate levels of glycation end-products (3). which causes accumulation of ad. and galactose elimination capacity is also higher in men than higher fruit and vegetable intake has convincingly been in women. type induced by galactose supplementation (20–24. By way of a nonenzymatic reaction with amino groups in proteins. there is sized from galactose taken up from the blood. rived galactose (51). 5. The conversion to galactitol by aldose reductase via the polyol pathway results in decreased availability of nicotinamide adenine di- nucleotide phosphate (NADPH) and glutathione. 17. 60) and some cancers (61). excess are not known. 62. the enzyme galactose-1-phosphate clear excess mortality rate was observed in men only above uridylyltransferase (GALT) in the Leloir breakdown pathway ≥3 glasses/day. resulting in UDP-glucose. and a the child. because galactose supplementation results in premature of galactose (Figure 4) has a higher activity in male animals aging in animals through induction of oxidative stress and than in female animals (7. breast milk. The association might have been an evolutionary survival mechanism for between milk and mortality was more modest in men. secondarily leading to free-radical formation oxidative stress and inflammation markers in human urine (56. Although the exact mechanisms milk consumption in women as compared with men. In addition.14 Michaëlsson et al. but it declines with increasing age (47–49). lipids. we have previously noted higher concentrations of dose reductase. culture cells also display evidence of lower-than-expected while twice that amount was necessary for the observation of antioxidant enzyme activities. shown to promote longevity (17. an inborn error of metabol- a consequence of an imbalance between prooxidant and ism resulting in early death without avoidance of galactose antioxidant defenses. suggesting that the normal excess mortality in men. This failure to find an fasting (52. pathway. 54. galactose reacts nonenzymatically with and serum with high consumption of milk (1). Oxidative stress induced by galactose is the main cause of galactosemia. With lower capacity of galactose degradation to glu- vanced glycation end-products and reactive oxygen species. and nucleic acids Uridine Diphosphate Galactose 4′- Epimerase (GALE) Advanced Glycation End UDP-Glucose Products (AGEs) Figure 4. 58). and only experimental evidence that fruits and vegetables or extracts one-third is made from endogenous synthesis (50). A sex difference in sensitivity to defenses might be compromised (2. By reducing oxidative stress and inflammation processes. and tissue mortality was seen with 1–2 glasses of milk per day in women. 53). Lactose from Milk Endogenous Production Lactase Galactose Dehydrogenase Galactose Galactonate Galactokinase (GALK) Aldose Reductase Galactitol Galactose-1-phosphate Free Radicals Galactose 1-Phosphate Uridyltransferase (GALT) Nonenzymatic reaction with UDP-Galactose amino groups in proteins. and supporting our results in women. 57). an alternative route is the polyol especially superoxide radicals and hydrogen peroxide (2–5). galactose is converted to advanced glycation end products (AGEs). 59) and reduce the risk of Galactose is used in the endogenous production of human cardiovascular disease (13. amino groups in proteins and peptides. where galactose is converted to galactitol by al- Indeed. and uridine diphosphate (UDP) galactose 4-epimerase (GALE). Overview of galactose metabolism. galactose-treated rodents. Most lactose in human breast milk is synthe. and nucleic acids. flies. which limited our possibility to detect an . Liver of them can rescue animals from the premature aging pheno- glycogen in infants is formed mainly from breast milk–de. Specifically. lipids. galactose-1-phosphate uridylyltransferase (GALT). Intriguingly. 63). galactose exposure has been identified experimentally (6–8). and it acts as a reservoir for subsequent We found no clear interaction between milk intake and hepatic glucose release to the circulation during times of fruit and vegetable intake in men. with increased production of free radicals (56). The major pathway of galactose metabolism (the Leloir pathway) operates via the enzymes galac- tokinase (GALK). GALT deficiency is also inflammation (2–5). 55). cose by the Leloir pathway. intake.

Sweden (Karl Michaëlsson. 2015. 1746S–1751S. Rautiainen S. et al. Michaëlsson K. A consideration in the SMC. et al. BMJ. The role of tree nuts Surgical Sciences. 1999. ond FFQ.5(5): sive FFQ administered in a setting with a wide range of 317–325. total antioxidant capacity estimates in Swedish women. J Nutr.349:g4490. Am J Med. Reuter S. 2014. Effect of a traditional ACKNOWLEDGMENTS Mediterranean diet on lipoprotein oxidation: a randomized controlled trial. Biogerontology. Levitan EB. Coban J. and peanuts in the prevention of coronary heart disease: Uppsala. Advanced glycation in the gene expression and activity of antioxidant enzymes D-galactose induced mouse aging model. Neurosci Lett. giving females an enhanced capacity to pro- impairment induced by D-galactose in mice. Uppsala. Stockholm.30(3):793–802. et al.349:g6015. we observed stronger estimates compared with of galactose toxicity in male and female chicks. Sweden 16. Langenskiold S. J Neurosci Res. 5. 490–497. vide mitigation of oxidative damage through an increased 2014. Karolinska Institutet. Zhang Q. BMJ. 2010. 2014. Furthermore. is associated with oxidative stress. and reproducibility of food-frequency questionnaire-based Conflict of interest: none declared. Harasym J. Zuo P. Uppsala University. 2013. Intake and serum tose intolerance. Chronic systemic D-galactose 21. Poultry Sci. intake of antioxidants (64). Hu FB.83(8):1584–1590. or to children and adolescents. et al.150(2):742–745. Blueberry exposure induces memory loss. Our results might not apply to people of other 10. Ros E. Estruch R. Nutrition. age and treatment time on brain oxidative stress and memory than in males. Fruit and vegetable consumption This work was supported by grants from the Swedish and mortality from all causes. Cui X.14(2): acid. Department of Medical Sciences. Byberg L. Salas-Salvado J. Manolagas SC. Aydin AF. Biochem J. Rautiainen S. Effect of fruit and vegetable mended requirements for fruit and vegetable intake (≥5 antioxidants on total antioxidant capacity of blood plasma. 13. Department of 15. Liisa Byberg). Bottai M. (Figure 1B). neurodegeneration. 2007. be. et al. Orsini N. and Unit of Nutritional Epidemiology. et al. 2014.571C:45–49. Gupta SC. damage in rats. Kucukgergin C. 2012. Fito M.49(11):1603–1616. Unit of multiple potential mechanisms. Zuo P. 2008. Gao J. Song X. adults question the value of recommending high consump. servings/day). 1. et al.368(14):1279–1290.39(4):802–812. Am J Clin Nutr. Serafini M. Oledzki R. the chick. The funding organization played no role in the design or 18. Kris-Etherton PM. Faculty of Medicine. Uppsala University. Milk. Ros E. Li D. Wilken DR. Betul-Kalaz E. 19. et al. 14. Chaturvedi MM. Trends ethnic origins.30(5):511–517. Galactose toxicity and activities of cause we used the individual personal identification number the galactose-metabolizing enzymes during development of for linkage to the death registry. cancer: systematic review and dose-response meta-analysis of prospective cohort studies. Faculty of Medicine. Questions regarding 1960. Metab Brain Dis. Sexual differences in galactose consistency in the results irrespective of whether fruit and metabolism: galactosyl ceramide galactosidase and other vegetable consumption or ORAC was used as the effect galactosidases in mouse kidney. Am J Clin Nutr. 2010.167(11):1195–1203. 1973. 3. consumption and all-cause mortality: a dose-response analysis. Ouyang Y. et al. Coban J. Dogan-Ekici I. Larsson SC. milk intakes and intakes of antioxidant foods. Mayes JS. Parfitt AM. 11. 2004. administered in 1997. D-galactose-caused life The main strengths of this study were the use of data shortening in Drosophila melanogaster and Musca domestica from 2 large population-based cohorts and the comprehen. especially in women not meeting the recom. 2014. and Mortality 15 interaction pattern with fruit and vegetables. cardiovascular disease. updated information and with a larger number of outcomes 8. What old means to bone. et al. Guxens M. et al. 2008. and Research Council. Parkhurst GW. 12. 2. et al. Antioxidant Foods. 7. but still the mortality rate inflammation. Bellavia A.125(10): 974–980. 17. tion of milk. Sweden (Alicja Wolk). Wang L. The validity conduct of the study.98(2):454–459. Hao L.87(5):1247–1253. such as those with a high prevalence of lac. Geriatr Gerontol Int. . et al. et al. 1125–1127. 9. and treatment attenuates D-galactose-induced oxidative stress and oxidative damage in mice: protective effects of R-alpha-lipoic tissue damage in rat liver. Radin NS. Bretthauer RK. 2013. Huang H. Milk intake 20. 2014. Author affiliations: Unit of Orthopedics.99(1):107–114. N Engl J Med. Wolk A. use of a single assessment of exposure.136(4): measure modifier. Lin YN. Bao M.21(6):369–374. Liu J.108(3):239–251. Blueberry treatment and risk of mortality and fractures in women and men: cohort decreased D-galactose-induced oxidative stress and brain studies. Am J Clin Nutr. et al. Fruit and vegetable (Håkan Melhus). We found 6. concentrations of alpha-tocopherol in relation to fractures in Our observational results in this population of Swedish elderly women and men: 2 cohort studies. Arch Biochem Biophys. Morgenstern R. Nordin JH. Oxidative stress. Wang X. Wolk A.138(9): Clinical Pharmacology. Loss to follow-up was negligible. et al. Through the use of time. Primary prevention of cardiovascular disease with a Mediterranean diet. Mech Ageing Dev. Total antioxidant capacity from diet and risk of myocardial infarction: a REFERENCES prospective cohort of women. Institute of Environmental Medicine. 1972. Michaëlsson K. Corella D. et al. and cancer: how are they linked? Free Radic patterns with a threshold at 5 servings/day were similar Biol Med. 2006. oxide dismutase) in animals seem to be higher in females 4. fruit and vegetable intake were more diversified in the sec. Cui X. Endocrinol Metab. Arch Intern Med. The influence of gender. (such as mitochondrial glutathione peroxidase and super.

Causal directed 56.livsmedelsverket. Hang D. concentrations of carbohydrates and sugar alcohols in term 34. Knol MJ.262(1):E46–E51. Epidemiology. Yonessi M. et al. Cavalli C. 47. Coffee drinking female chicks. Willett W.19(5):1341–1348.88(4):1083–1087. Bjerselius R. Nardini M. 2016. 31. New York. 1991.19(8):1707–1714. Gross SK.50(21):6211–6216. The relationship of risk in a prospective study of Swedish women and men.61(11):1063–1074. Mohammadirad A. 2008. stress contributes to outcome severity in a Drosophila . Nutritional Epidemiology. Haglund L. et al. Hepatology. Brennan P. Contribution of plasma Sweden: Livsmedelsverket (National Food Agency). Med Care. women. 2012. et al. Charlson ME. Bergkvist L. Andersson SO. classifying prognostic comorbidity in longitudinal studies: IUBMB Life.40(5): 58. Crippa A. Bua V. Timpson NJ. Am J galactose-1-phosphate accumulation and uridyl transferase Clin Nutr. et al. Exp Eye Res. Acta Med 30. TX: Stata Press.43:439–447. 45. Badiei S. Cultured lambs. Much ado about nothing: a IMOD™ and Angipars™ on mouse D-galactose-induced comparison of missing data methods and software to fit model of aging. Wierenga KJ. 39. cardiovascular Brussels. A new method of 57. Johansson JE. Thomas LD. Lactase persistence and lipid exposure and fracture incidence among men: a pathway selection in the Maasai. Wagh K. Galactose toxicity in animals. 49. activity to the differential galactose toxicity in male and 36. 2010.26(5):593–599. 25. Dietary cadmium 46. et al. Fruit and Vegetable 43. 2011.16 Michaëlsson et al. Dietary calcium Scand. Pompei P. galactose. yoghurt. Daru.175:281–289. Am Stat. milk. 2007. Corella D.68(4):457–464. Boffetta PL. Tigas S. Willett WC. 3rd ed.257(5):E697–E703. Biochem Biophys Res Commun. McCluer RH. Kubo E. Halfon P. Jumbo-Lucioni PP. version. Quan H. (Livsmedelsverkets rapportserie no. 2010. Dietary Guidelines—Risk and Benefit Management Report. Bergstrom L. production. Byberg L. Belgium: European Food Information Council. Couto E.102(8):529–537. 2013. Hepatic metabolism of Vår Föda.61(1): 24. et al. Lai K. Kliegman R. Swedish capacity and liver volume in aging man. Hansson LM. Harwood JE. 2002. Oxidative 373–383. 51. et al. et al. Sparks JW. 2012. and dairy intake in relation to bladder cancer 54. The galactose elimination capacity in control 2011. et al. Wolk A. Lauterburg BH. et al. Spedale SB. 2008. Effects of 41. Giannetti I. and problems in the application of Mendelian randomization. Nutrients. 2003. Brugård Konde Å. Galanti MR. Kylberg E. Michaëlsson K. intake and breast cancer risk in a prospective cohort of 1986. Hagman U. Mayes JS. et al. Melhus H.16(11):1170–1180. Larsson SC. Hernan MA. 79–90. Release 11. development and validation.pdf. Iran J Basic Med analyses of effect modification and interaction. Am J Physiol. and cancer: a systematic review and meta-analysis. Plasma 2000. Oxford University Press. Adjustment for total LCT-13910C>T polymorphism with obesity and its energy intake in epidemiologic studies. 50. Am J self-reported food consumption: how shall we treat partial Physiol. Coltell O. Trindade C. 2009. Stata Reference Manual. J Lipid Res. galactose and glucose to milk lactose synthesis during http://www. Long-term dietary calcium aminopyrine demethylation and caffeine clearance. Elsas LJ. Hopson ML.7(9):e44751. administrative data.20(1):68. VanderWeele TJ. Am J Clin Nutr.342:d1473. 1992. et al. Kushi LH. 52. Galactose elimination 32. 29. Marchesini G. 22. 2012. 2011.43(11):1130–1139. Brunori A. Gaborieau V. 8(5):1079–1083. Natella F. Julin B. Horton NJ. 1999. Kunst C. NY: Cancer Epidemiol Biomarkers Prev. 2012. 26. J Natl Cancer between renal cell carcinoma and milk drinking? Potentials Inst. Can lactase intake and overall cancer risk in the European Prospective persistence genotype be used to reassess the relationship Investigation into Cancer and Nutrition (EPIC). 2015.19(5):720–728. Myers FK. 1988. Larsson SC. Am J Clin Nutr. 2009. 65(4 suppl):1220S–1228S. glucose. Pediatr Res. Robins JM. Cataract formation acyclic graphs and the direction of unmeasured confounding through the polyol pathway is associated with free radical bias. Schnegg M. Fukuda M. The glucose-galactose 33.se/globalassets/rapporter/2015/ galactose ingestion. Int J Sci. mice. Arregui M. Wichmann J. College glycosphingolipids in kidney slices from male and female Station. et al. et al.39(4): influences plasma antioxidant capacity in humans.88(1): rapp-hanteringsrapport-engelska-omslag–inlaga–bilagor-eng. Alexe G. information system for nutritive values of food [in Swedish]. 55. J Agric 661–665. 1989. J Clin Endocrinol Metab. Howe GR. Food Chem. 2015. Uppsala. 2008. Warensjö E. et al. nonresponse in a food frequency questionnaire? Nutr Cancer. Epidemiol. 5/2015). Anti-aging effects of some selected Iranian folk 42. population-based prospective cohort study. Accessed April 21.4(2):69–77. Diet-associated risks of disease and paradox in neonatal murine hepatic glycogen synthesis. Kleinman KP. Obesity.3(2):164–171. Bhatia A. 53. Orsini N. Quantitative liver function in the longitudinal cohort study. disease. Ales KL.26(7):1601–1608. BMJ. 1970. J Hepatol. modulation by dairy products in a Mediterranean population. 23. 2013. 1964. Sundararajan V. Fruit and vegetable 44. The food newborns after milk feeding. intake and risk of fracture and osteoporosis: prospective 48. European Food Information Council. elderly assessed by galactose elimination capacity. and lactate after milk feeding in newborn 35. Mohammadirad A. et al. J Bone Miner Res. Biosynthesis of neutral 37. Miller LR. Tygstrup N. 1987. Non-fermented milk Consumption in Europe—Do Europeans Get Enough? consumption and mortality from all causes. Aghamohammadali-Sarraf F. incomplete data regression models. 225–229.41(2):514–520. subjects and in patients with cirrhosis of the liver. et al. Brown LD. Stefek M. Natural flavonoids as potential multifunctional 40. StataCorp LP. 38. Miyoshi N. Ghanbari S. et al. 1985. 2005.7(9):7749–7763. Coding algorithms agents in prevention of diabetic cataract. VanderWeele TJ. Larsson SC. Recommendations for presenting medicinal herbs—biochemical evidences.36(1):1–6. Association of the 28.89(1):277–282. Battaglia FC. J Chronic Dis. 1997. Haymond MW.64(2): composition database KOST: the National Administration’s 189–193. for defining comorbities in ICD-9-CM and ICD-10 2011. 2009. PLoS One. Sunehag A. Interdiscip Toxicol. 27. et al.

mitochondrial complex I deficiency in mouse skeletal muscle: 59. et al. Chang L. Liu J. Cereb Cortex. Antioxidant Foods. Giacosa A. et al. 64. Liu X. Ursolic acid attenuates 240–246.6(1):84–94. Wu DM. Dis Model Mech. Free Radic Biol Med.22(1):90–95. 2011. Lancet. D-galactose induces a 2013. Bavaresco L. 2014. Lu J. MacGregor GA. 2006. Shu XO. Zhang X. et al. Am J Clin Nutr. D-galactose-induced inflammatory response in mouse 60. Nowson CA. 62. Garcia-Sala D. cardiovascular disease mortality. Cancer prevention in females exhibit higher antioxidant gene expression and lower Europe: the Mediterranean diet as a protective choice. Milk.94(1): 63. Cancer Prev. Xiang YB. Eur J oxidative damage than males. Fruit and vegetable prefrontal cortex through inhibiting AGEs/RAGE/NF-kappaB consumption and stroke: meta-analysis of cohort studies. Sastre J.367(9507):320–326. and Mortality 17 melanogaster model of classic galactosemia.20(11):2540–2548. Zheng YL. Barale R. 2013. 2003. 34(5):546–552. Cruciferous vegetable potential benefits of nutrient combination in ameliorating consumption is associated with a reduced risk of total and muscle impairment. Borras C. Mitochondria from 61. J Med Food. . et al. pathway activation. et al. 2010.17(3):357–364. He FJ.