1 Introduction

In the modern area, as global life expectancy continues to rise, women find themselves dedicating around one-third of their lives to post-menopause. During this phase, they encounter a variety of challenges including decreased estrogen levels, vascular instability, HTN, T2DM, Heightened sweating, osteoporosis, cardiovascular ailments, degeneration of the reproductive and urinary systems, and psychological disorders [1].

A well-known side effect of T2DM is HTN, while diabetes is a well-known side effect of hypertension [2]. The odds of HTN and T2DM in postmenopausal women vary globally, according to available data, the odds of hypertension in postmenopausal women globally range from ~ 40% to 60% [3]. As for diabetes mellitus, the prevalence in postmenopausal women varies across different regions. Studies have reported rates ranging from 10 to 25% globally [4]. Individuals with diabetes may also experience elevated blood pressure, and ~ 40–60% of diabetes cases are accompanied by hypertension [5]. The risk of developing HTN and T2DM increases with age and other factors such as obesity, sedentary lifestyle, and family history. Postmenopausal hormonal changes may also contribute to the development or worsening of hypertension and decreased estrogen levels, can also influence glucose metabolism, and contribute to the development of diabetes in susceptible women [3, 6].

Nutrition is generally understood to play a role in the development of no communicable illnesses. Previous studies have also shown that changing one's diet to include more fruits and vegetables and less sweets is one of the greatest approaches to avoiding hypertension and enhancing lipid profiles [7, 8] Lower intakes are linked to disorders including T2DM and metabolic syndrome (MetS) [9]. However, due to the diverse array of dietary patterns and their robust connection to various chronic ailments, numerous nutritional indices have been developed. Two prominent ones among these are the Mediterranean Diet Score (MED) and the Healthy Eating Index (HEI). A common thread between these two scoring systems is their emphasis on encouraging higher intake of vegetables and fruits within one's diet, and they have been associated with a decreased risk of various health problems like hypertension and kidney stones [7, 10].

This large-scale multinational cohort study has investigated the associations between dietary patterns and health outcomes, including cardiovascular disease and mortality. It has provided insights into the impact of different dietary components on health across diverse populations [11].

The Dietary Approaches to Stop Hypertension (DASH) diet has been extensively studied for its effects on blood pressure and cardiovascular health. Recent trials and updates have explored variations of the DASH diet and its relevance in modern dietary recommendations [12].

While both rankings consider the presence of saturated and unsaturated fatty acids, it's important to note that the Mediterranean diet promotes reduced dairy consumption and does not endorse the consumption of sweetened drinks with artificial sweeteners. These constraints have prompted the creation of an innovative scoring system called the LLDS. This scoring method is crafted using the 2015 Dutch dietary guidelines, which have a foundation in scientific research and thorough investigations into the relationships between different foods, dietary habits, and chronic illnesses [13, 14]. This dietary score encompasses nine healthful food groups, including fruits, legumes, whole grains, nuts, vegetables, oils, fish, soft margarine, unsweetened dairy, tea, and coffee, along with three less healthy food groups, comprising sugar-sweetened beverages, processed and red meat, and butter and hard margarine [13, 14].

Given this information and the absence of prior investigations into the relationship between LLDS, T2DM, and HTN, our study was conducted to investigate the potential link between the Lifelines Diet Score and the prevalence of T2DM and HTN among postmenopausal women.

2 Methods

This study is a cross-sectional investigation carried out at a single facility. A total of 1350 Kurdish women, aged between 47 and 65 years, participated in the present study. Women with a history of cancer, those unable to provide informed consent, and those using Hormone Replacement Therapy (HRT) were excluded as per the study's design. The final study population consisted of 1341 adults (see Fig. 1). The study team, which consisted of a physician, lab technicians, an executive supervisor, and a receptionist, gathered demographic information such as level of education, woman, age, residence, marital status, socioeconomic standing (SES), cigarette smoking, intake of food, and levels of physical activity (PA) [very low: 600, low: 600–3000, and moderate and high > 3000 MET-min/week] as well as other primary data [15], both the composition of the body and measurement of anthropometric characteristics.

Fig. 1
figure 1

Flow chart of the cross-sectional study in the study participants

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2.1 Collecting blood samples and conducting biochemical assays

Following an overnight fast of 8–12 h, 7 mL of blood was drawn into clot tubes and subsequently processed for serum isolation via centrifugation at 4 °C for 10–15 min. The serum samples were then stored at – 80 °C until biochemical analysis. High-density lipoprotein cholesterol (HDL-C), Low-density lipoprotein cholesterol (LDL-C), triglycerides (TG), total cholesterol (TC), fasting blood sugar (FBS), and glycated hemoglobin (HbA1c) levels were quantified using validated, commercially available assays following the manufacturer's protocols. Specifically, HDL-C and LDL-C were measured using enzymatic methods, while TG and TC were assessed via colorimetric assays. FBS was determined using the glucose oxidase–peroxidase method, and HbA1c levels were quantified using high-performance liquid chromatography (HPLC). These standardized procedures ensure the reliability and reproducibility of our biochemical measurements, contributing to the robustness of our study methodology.

2.2 Dietary assessment

The Food Frequency Questionnaire (FFQ), a 147-item questionnaire, was found to be reliable and accurate [16]. This was provided in person by qualified nutritionists and includes a shopping list and the typical serving size for each meal item. Participants gave their daily, weekly, monthly, and yearly consumption rates for each beverage. The amount of food consumed was computed using a customized version of the NUTRITIONIST IV program for Kurdish cuisine (version 7.0; N-Squared Computing, Salem, OR, USA) and translated to grams using home measurements [17].

2.3 Lifelines Diet Score

The LLDS (Lifestyle and Diet Score) is a method used to evaluate individuals based on the quality of their diet, employing the Vinke et al. approach [14]. A more comprehensive explanation of this nutritional assessment can be found elsewhere [13, 18]. In brief, the LLDS adheres to the 2015 Dutch dietary guidelines, which are rooted in scientific evidence. It encompasses nine food groups known to have beneficial effects on health, including legumes, fruits, nuts, vegetables, whole grain products, oils, soft margarine, fish, unsweetened dairy, tea, and coffee. Additionally, it incorporates three food groups associated with less favorable health outcomes, namely processed and red meat, hard margarine, butter, and sugar-sweetened beverages. For each food group, individuals' food consumption is quantified in grams per 1000 kcal. The intake is categorized into quintiles, with 5 points assigned for the highest consumption and 1 point for the lowest for the beneficial food groups on health, while the reverse applies to detrimental food groups on health. The LLDS score, ranging from 12 to 60, is determined by summing the scores from these 12 components [13, 18].

2.4 Hypertension and type 2 diabetes mellitus assessment

A systolic blood pressure (SBP) of at least 140 mmHg, a diastolic blood pressure (DBP) of at least 90 mmHg, or the use of antihypertensive medication as therapy were considered indicators of hypertension (HTN) [7, 19]. For individuals without diabetes: Normal HbA1c in mmol/mol is typically less than 42 mmol/mol and fasting blood sugar (FBS) level of less than 126 mg/dl, the use of diabetic medications, or a physician's confirmation of a diabetes diagnosis were considered to be indicators of T2DM [20].

2.5 Statistical analysis

We calculated the mean and standard deviation for numerical data. LLDS tertiles were used to calculate the frequency (%) for qualitative characteristics. Additionally, we used a one-way analysis of variance (ANOVA) to see whether there were any notable differences in the means of constant variables among LLDS tertiles (T1: 30, T2: 31–39, and T3: 40). Our study participants was categorized into tertiles for the analysis. The decision to use tertiles rather than quartiles was based on several considerations specific to our research objectives and dataset characteristics. Tertiles were chosen to ensure adequate statistical power given the sample size and to facilitate straightforward comparison across distinct LLDS categories within our study population.

We performed the Chi-square test to see whether there were any categorical characteristics among LLDS tertiles that differed significantly. Using one-way ANOVA, we also determined the mean and standard deviation for anthropometric and biochemical traits in each of the four study groups (Healthy, HTN, T2DM, and HTN).

We used simple and adjusted logistic regression models to examine the association between LLDS, HTN, and T2DM. Potential confounding variables such as age, waist-hip ratio (WHR), BMI kg/m2, protein (%E), carbohydrate (%E), physical activity (%E), and oil/fat (%E) were taken into account while creating these models. We provided the 95% confidence intervals for the crude and adjusted odds ratios. P-values of 0.05 or less were regarded as statistically significant. SPSS version 25.0 (Statistical Package for the Social Sciences) was used for all statistical calculations.

3 Results

Baseline characteristics and dietary intakes of the participants according to LLDS Tertiles are provided in Table 1. Women in the first tertile were older than women in the second and third tertile, (P < 0.001). 466 (34.8%) of the respondent's Socioeconomic status is high. Of the 1341 women, 561(41.8%) had no disease and were healthy, while 403(30.1%) had T2DM and HTN and 195(14.5%) had T2DM only and 182(13.6%) had HTN only, (P < 0.001). also women in tertile 1 had relatively higher BMI (27.92 ± 2.21) than those in tertile 3 (23.65 ± 2.65), (P < 0.001). TG, T-C, and LDL-C are much higher in women in the first tertile than in the second and third tertiles, (P < 0.001).

Table 1 Baseline characteristics and Dietary intakes of the participants according to LLDS Tertiles (N = 1341)
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In terms of systolic blood pressure, there was a reduction from T1 (137 ± 29 mmHg) to T2 (107 ± 15 mmHg) and further to T3 (106 ± 14 mmHg). also, diastolic blood pressure showed a significant decrease across the three-time points, with values in T1 (98 ± 23 mmHg) dropping to T2 (72 ± 12 mmHg) and further to T3 (71 ± 11 mmHg). Additionally, the HbA1c levels exhibited a consistent decrease, moving from T1 (48.03 ± 13.14 mmol/mol) to T2 (34.66 ± 7.22 mmol/mol) and T3 (30.69 ± 7.51 mmol/mol). Lastly, fasting blood sugar (FBS) levels was showed a significant decline from T1 (120.73 ± 33.46 mg/dL) to T2 (96.37 ± 18.91 mg/dL) and T3 (85.13 ± 18.32 mg/dL).

Compared to women in the second and third tertile, women in the third tertile consume considerably more vegetables, nuts, whole grain products, unsweetened dairy, soft margarine, fruits, fish, tea, and coffee (T1 vs T2: P < 0.001, T1 vs T3: P < 0.001). Contrarily, compared to the second and third tertiles, women from the first tertile consume more bad food categories, including red and processed meat, butter and hard margarine, sugar, and sweetened drinks (T1 vs T2: P < 0.001, T1 vs T3: P < 0.001). Additionally, the top tertile had a larger total fat consumption than the second and third tertile, but the third tertile had higher calorie, carbohydrate, and protein intakes (T1 vs T2: P < 0.001, T1 vs T3: P < 0.001).

Table 2 presents the multivariate-adjusted means and odds ratios (ORs) with 95% confidence intervals (CIs) for HTN and T2DM across tertiles of the LLDS. For hypertension, across models adjusting for different variables (Model I: crude; Model II: adjusted for age and energy intake; Model III: adjusted for age, energy intake, carbohydrates, protein, fat, physical activity, BMI, socioeconomic status), the odds of HTN decreased significantly from T1 to T3 of LLDS: ORs ranged from 0.72 to 0.41 in Model III (P < 0.001). Similarly, for T2DM, LLDS tertiles showed a consistent inverse association: ORs ranged from 0.92 to 0.50 in Model III (P < 0.001). These findings underscore a robust inverse relationship between LLDS and both hypertension and T2DM after adjusting for various potential confounders, indicating that adherence to a higher LLDS is associated with lower odds of these chronic conditions.

Table 2 The multivariate-adjusted means for HTN and T2DM according to tertiles (T) of the LLDS
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4 Discussion

In the current study, we investigated the relationships between T2DM and HTN, and LLDS in postmenopausal women. In this study, a strong correlation between LLDS and both T2DM and HTN were discovered in our postmenopausal women sample. Additionally, substantial trends in T2DM and HTN chances were seen as LLDS adherence increased. The LLDS was developed specifically for the Dutch population, utilizing data from the Lifelines cohort, a large, multi-generational study in the Netherlands. This localization allows the score to account for dietary habits, food availability, and cultural practices unique to this population. The LLDS focuses on a comprehensive dietary assessment that includes a wide range of food groups and nutrients. It incorporates both beneficial and adverse dietary components, allowing for a balanced evaluation of an individual's diet [13, 21].

Our study findings indicate a positive correlation between LLDS and T2DM. Notably, participants in the third tertile exhibited a 45% reduced risk of developing diabetes mellitus, with an odds ratio (OR) of 0.55. This outcome aligns with the research conducted by Vinke et al., who also explored the association between LLDS and type 2 diabetes. Their study demonstrated that LLDS could lower the risk of T2DM within the Dutch Lifelines cohort [22]. Similarly, Khani et al. conducted a comparable study involving 278 obese women in 2020. with the same root effect mechanism which demonstrated a higher LLDS and better sleep quality relationship [18].

As introduced earlier, the LLDS serves as an indicator of relative diet quality based on adherence to the Dutch Dietary Guidelines, which have been shown to enhance dietary quality [13]. Previous research has demonstrated associations between healthy dietary patterns and the risk of T2DM. While limited research has explored the link between the Healthy Eating Index (HEI) and T2DM, a high HEI score may be linked to a reduced risk of developing T2DM [23]. Better adherence to the Mediterranean diet was linked to a 19% decreased incidence of type 2 diabetes in a meta-analysis of eight cohort studies including 122,810 people. Indicating the long-term protective impact of this dietary pattern [24]. Additionally, another meta-analysis by Koloverou et al. reported a 23% reduction in the odds of type 2 diabetes in those with maximal or minimal adherence to the Mediterranean diet questionnaire.

Turning to the relationship between LLDS and hypertension (HTN), our study revealed a positive association. Participants in the third tertile exhibited a 38% reduced risk of developing hypertension compared to those in the first and second tertiles, with an odds ratio (OR) of 0.62. Currently, there is a paucity of research on LLDS and HTN, making it challenging to directly compare our findings with prior studies. Nevertheless, earlier research has established connections between healthy dietary patterns and the risk of HTN. In a prospective Spanish cohort study, for example, adherence to the Mediterranean diet was associated with modest changes in mean systolic and diastolic blood pressure levels over six years, showing that adhering to that diet was linked with modest changes in mean systolic and diastolic blood pressure levels, suggesting a potential role in mitigating age-related blood pressure changes [25]. Additionally, a recent randomized controlled trial (RCT) by Davis et al. showed that intakes of the Mediterranean diet for 6 months led to significantly lower blood pressure levels compared to individuals on their usual diet [26].

Despite the evidence supporting the relationship between healthy dietary patterns and the risk of T2DM and HTN, it's important to acknowledge that LLDS, as introduced in our study, differs from other dietary indices, limiting direct comparisons with prior research [27]. Furthermore, a study by Fateh et al. in 2022 found a positive relationship between a higher inflammatory score and HTN, emphasizing the potential impact of antioxidants in preventing hypertension [7].

In line with these observations, our study’s Table 2 data indicated that individuals in the highest LLDS tertile consumed more vegetables and fruits while consuming less red and processed meat compared to those in the 1st and 2nd tertile. Fruits, berries, and vegetables are rich sources of fiber, antioxidants, minerals, vitamins, phytochemicals, carotenoids, and polyphenolic compounds, all of which may have beneficial effects on glucose metabolism [28, 29]. These components are believed to exert protective effects against pro-inflammatory markers such as interleukin-6 (IL-6) [30].

Numerous studies have indicated that Western dietary patterns, characterized by higher intake of processed meat, red meat, and refined grains, are strongly associated with increased odds of type 2 diabetes and hypertension [31, 32]. For instance, in a 12-year cohort study involving 42,504 American participants, Van Dam et al. found a 60% elevated risk of type 2 diabetes among those adhering to a Western diet [33]. Additionally, animal studies have shown that nitrosamines in meat may be toxic to pancreatic beta cells, elevating the risk of T2DM [34].

This study has several strengths. First, it utilizes the Lifelines Diet Score (LLDS) to evaluate dietary patterns, which provides a comprehensive assessment of food consumption and its association with health outcomes. Second, the large sample size enhances the generalizability of the findings to a broader population. Third, the focus on postmenopausal women addresses a critical demographic often underrepresented in dietary studies.

However, the study also has several limitations. One major limitation is its cross-sectional design, which precludes establishing causality between diet and health outcomes such as T2DM and HTN. And a significant limitation of our study is the exclusion of women using Hormone Replacement Therapy (HRT). This exclusion was implemented to control for the confounding effects of HRT on the risk factors under investigation, ensuring that our results were not influenced by these variables. However, this decision may impact the generalizability of our findings, particularly regarding postmenopausal women who are on HRT. Consequently, our results may not fully represent the risk profiles and outcomes of this subgroup. To address this limitation, future research should consider including women using HRT or performing subgroup analyses to better understand the specific impact of HRT on the studied risk factors. This approach would provide a more comprehensive understanding and enhance the applicability of the findings to a broader population.

5 Conclusion

Following a diet with a higher LLDS was associated with reduced odds of T2DM and HTN in postmenopausal women. Future prospective studies in this field are recommended to provide a more comprehensive assessment of the relationship.