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Ban M, Feng W, Hou M, Zhang Z, Cui L. IVF exposure induced intergenerational effects on metabolic phenotype in mice. Reprod Biomed Online 2024; 49:103992. [PMID: 38889592 DOI: 10.1016/j.rbmo.2024.103992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 03/20/2024] [Accepted: 04/09/2024] [Indexed: 06/20/2024]
Abstract
RESEARCH QUESTION What is the potential transmission of metabolic phenotype from IVF offspring to the subsequent generation? DESIGN An IVF mouse model was established. The F1 generation mice were produced though IVF or natural mating and the F2 generation was obtained through the mating of F1 generation males with normal females. Their metabolic phenotype, including systemic and hepatic glucolipid metabolism, was examined. RESULTS It was found that IVF F1 males exhibited metabolic changes. Compared with the control group, the IVF F1 generation showed increased body weight, elevated fasting glucose and insulin, and increased serum triglyceride concentrations. IVF F1 mice also showed an increased expression of hepatic lipogenesis and autophagy genes. Moreover, IVF F1 males transmitted some metabolic changes to their own male progeny (IVF F2) in the absence of a dietary challenge. IVF F2 mice had increased peri-epididymal and subcutaneous fat and decreased insulin sensitivity. Under the 'second hit' of a high-fat diet, IVF F2 mice further showed increased hepatic lipid deposition with unaltered autophagy levels. CONCLUSION This research demonstrates the impact of IVF on hepatic glucose-lipid metabolism in two successive generations of offspring, highlighting the need for additional investigation. Enhanced understanding of the mechanisms underlying the transmission of multigenerational effects induced by IVF could potentially lead to the advancement of therapeutic interventions for individuals experiencing infertility.
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Affiliation(s)
- Miaomiao Ban
- State Key Laboratory of Reproductive Medicine and Offspring Health, Center for Reproductive Medicine, Institute of Women, Children and Reproductive Health, Shandong University, Shandong, China.; National Research Center for Assisted Reproductive Technology and Reproductive Genetics, Shandong University, Shandong, China.; Key Laboratory of Reproductive Endocrinology (Shandong University), Ministry of Education, Shandong, China.; Shandong Technology Innovation Center for Reproductive Health, Shandong, China.; Shandong Provincial Clinical Research Center for Reproductive Health, Shandong, China.; Shandong Key Laboratory of Reproductive Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China.; Research Unit of Gametogenesis and Health of ART-Offspring, Chinese Academy of Medical Sciences (No. 2021RU001), Shandong, China
| | - Wanbing Feng
- State Key Laboratory of Reproductive Medicine and Offspring Health, Center for Reproductive Medicine, Institute of Women, Children and Reproductive Health, Shandong University, Shandong, China.; National Research Center for Assisted Reproductive Technology and Reproductive Genetics, Shandong University, Shandong, China.; Key Laboratory of Reproductive Endocrinology (Shandong University), Ministry of Education, Shandong, China.; Shandong Technology Innovation Center for Reproductive Health, Shandong, China.; Shandong Provincial Clinical Research Center for Reproductive Health, Shandong, China.; Shandong Key Laboratory of Reproductive Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China.; Research Unit of Gametogenesis and Health of ART-Offspring, Chinese Academy of Medical Sciences (No. 2021RU001), Shandong, China
| | - Min Hou
- State Key Laboratory of Reproductive Medicine and Offspring Health, Center for Reproductive Medicine, Institute of Women, Children and Reproductive Health, Shandong University, Shandong, China.; National Research Center for Assisted Reproductive Technology and Reproductive Genetics, Shandong University, Shandong, China.; Key Laboratory of Reproductive Endocrinology (Shandong University), Ministry of Education, Shandong, China.; Shandong Technology Innovation Center for Reproductive Health, Shandong, China.; Shandong Provincial Clinical Research Center for Reproductive Health, Shandong, China.; Shandong Key Laboratory of Reproductive Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China.; Research Unit of Gametogenesis and Health of ART-Offspring, Chinese Academy of Medical Sciences (No. 2021RU001), Shandong, China
| | - Zhirong Zhang
- State Key Laboratory of Reproductive Medicine and Offspring Health, Center for Reproductive Medicine, Institute of Women, Children and Reproductive Health, Shandong University, Shandong, China.; National Research Center for Assisted Reproductive Technology and Reproductive Genetics, Shandong University, Shandong, China.; Key Laboratory of Reproductive Endocrinology (Shandong University), Ministry of Education, Shandong, China.; Shandong Technology Innovation Center for Reproductive Health, Shandong, China.; Shandong Provincial Clinical Research Center for Reproductive Health, Shandong, China.; Shandong Key Laboratory of Reproductive Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China.; Research Unit of Gametogenesis and Health of ART-Offspring, Chinese Academy of Medical Sciences (No. 2021RU001), Shandong, China
| | - Linlin Cui
- National Research Center for Assisted Reproductive Technology and Reproductive Genetics, Shandong University, Shandong, China.; Key Laboratory of Reproductive Endocrinology (Shandong University), Ministry of Education, Shandong, China.; Shandong Technology Innovation Center for Reproductive Health, Shandong, China.; Shandong Provincial Clinical Research Center for Reproductive Health, Shandong, China.; Shandong Key Laboratory of Reproductive Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China.; Research Unit of Gametogenesis and Health of ART-Offspring, Chinese Academy of Medical Sciences (No. 2021RU001), Shandong, China.; State Key Laboratory of Reproductive Medicine and Offspring Health, Center for Reproductive Medicine, Institute of Women, Children and Reproductive Health, The Second Hospital, Shandong University, Shandong, China..
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Vázquez-Sánchez A, Rodríguez-Ríos D, Colín-Castelán D, Molina-Torres J, Ramírez-Chávez E, Romo-Morales GDC, Zaina S, Lund G. Effects of paternal arachidonic acid supplementation on offspring behavior and hypothalamus inflammation markers in the mouse. PLoS One 2024; 19:e0300141. [PMID: 38512839 PMCID: PMC10956830 DOI: 10.1371/journal.pone.0300141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 02/21/2024] [Indexed: 03/23/2024] Open
Abstract
Arachidonic acid (AA) is involved in inflammation and plays a role in growth and brain development in infants. We previously showed that exposure of mouse sires to AA for three consecutive generations induces a cumulative change in fatty acid (FA) involved in inflammation and an increase in body and liver weight in the offspring. Here, we tested the hypothesis that paternal AA exposure changes the progeny's behavioral response to a proinflammatory insult, and asked whether tissue-specific FA are associated with that response. Male BALB/c mice were supplemented daily with three doses of AA for 10 days and crossed to non-supplemented females (n = 3/dose). Two-month-old unsupplemented male and female offspring (n = 6/paternal AA dose) were exposed to Gram-negative bacteria-derived lipopolysaccharides (LPS) or saline control two hours prior to open field test (OFT) behavioral analysis and subsequent sacrifice. We probed for significant effects of paternal AA exposure on: OFT behaviors; individual FA content of blood, hypothalamus and hypothalamus-free brain; hypothalamic expression profile of genes related to inflammation (Tnfa, Il1b, Cox1, Cox2) and FA synthesis (Scd1, Elovl6). All parameters were affected by paternal AA supplementation in a sex-specific manner. Paternal AA primed the progeny for behavior associated with increased anxiety, with a marked sex dimorphism: high AA doses acted as surrogate of LPS in males, realigning a number of OFT behaviors that in females were differential between saline and LPS groups. Progeny hypothalamic Scd1, a FA metabolism enzyme with documented pro-inflammatory activity, showed a similar pattern of differential expression between saline and LPS groups at high paternal AA dose in females, that was blunted in males. Progeny FA generally were not affected by LPS, but displayed non-linear associations with paternal AA doses. In conclusion, we document that paternal exposure to AA exerts long-term behavioral and biochemical effects in the progeny in a sex-specific manner.
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Affiliation(s)
| | | | - Dannia Colín-Castelán
- Division of Health Sciences, Department of Medical Sciences, University of Guanajuato, Leon Campus, Leon, Gto., Mexico
| | - Jorge Molina-Torres
- Department of Biotechnology and Biochemistry, CINVESTAV Irapuato Unit, Irapuato, Mexico
| | | | | | - Silvio Zaina
- Division of Health Sciences, Department of Medical Sciences, University of Guanajuato, Leon Campus, Leon, Gto., Mexico
| | - Gertrud Lund
- Department of Genetic Engineering, CINVESTAV Irapuato Unit, Irapuato, Mexico
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Jeong B, Kim JS, Kwon AR, Lee J, Park S, Koo J, Lee WS, Baek JY, Shin WH, Lee JS, Jeong J, Kim WK, Jung CR, Kim NS, Cho SH, Lee DY. Maternal nanoplastic ingestion induces an increase in offspring body weight through altered lipid species and microbiota. ENVIRONMENT INTERNATIONAL 2024; 185:108522. [PMID: 38401434 DOI: 10.1016/j.envint.2024.108522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 01/13/2024] [Accepted: 02/19/2024] [Indexed: 02/26/2024]
Abstract
The rapidly increasing prevalence of obesity and overweight, especially in children and adolescents, has become a serious societal issue. Although various genetic and environmental risk factors for pediatric obesity and overweight have been identified, the problem has not been solved. In this study, we examined whether environmental nanoplastic (NP) pollutants can act as environmental obesogens using mouse models exposed to NPs derived from polystyrene and polypropylene, which are abundant in the environment. We found abnormal weight gain in the progeny until 6 weeks of age following the oral administration of NPs to the mother during gestation and lactation. Through a series of experiments involving multi-omic analyses, we have demonstrated that NP-induced weight gain is caused by alterations in the lipid composition (lysophosphatidylcholine/phosphatidylcholine ratio) of maternal breast milk and he gut microbiota distribution of the progeny. These data indicate that environmental NPs can act as obesogens in childhood.
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Affiliation(s)
- Bohyeon Jeong
- Rare Disease Research Center, Korea Research Institute of Bioscience and Biotechnology (KRIBB), 125 Gwahak-ro, Yuseong-gu, Daejeon 34141, South Korea
| | - Ji-Sun Kim
- Korean Collection for Type Cultures, Korea Research Institute of Bioscience and Biotechnology (KRIBB), Jeongeup, 56212, South Korea
| | - A Ra Kwon
- Chemical Analysis Center, Korea Research Institute of Chemical Technology (KRICT), Daejeon 34114, South Korea
| | - Jangjae Lee
- Chemical Analysis Center, Korea Research Institute of Chemical Technology (KRICT), Daejeon 34114, South Korea; Department of Chemistry, Korea University, Seoul 02841, South Korea
| | - Subin Park
- Rare Disease Research Center, Korea Research Institute of Bioscience and Biotechnology (KRIBB), 125 Gwahak-ro, Yuseong-gu, Daejeon 34141, South Korea
| | - Jahong Koo
- Rare Disease Research Center, Korea Research Institute of Bioscience and Biotechnology (KRIBB), 125 Gwahak-ro, Yuseong-gu, Daejeon 34141, South Korea; KRIBB School, Korea University of Science and Technology (UST), Daejeon, South Korea
| | - Wang Sik Lee
- Environmental Disease Research Center, Korea Research Institute of Bioscience and Biotechnology (KRIBB), 125 Gwahak-ro, Yuseong-gu, Daejeon 34141, South Korea
| | - Jeong Yeob Baek
- Rare Disease Research Center, Korea Research Institute of Bioscience and Biotechnology (KRIBB), 125 Gwahak-ro, Yuseong-gu, Daejeon 34141, South Korea
| | - Won-Ho Shin
- Department of Predictive Toxicology, Korea Institute of Toxicology, Daejeon 34114, South Korea
| | - Jung-Sook Lee
- Korean Collection for Type Cultures, Korea Research Institute of Bioscience and Biotechnology (KRIBB), Jeongeup, 56212, South Korea; KRIBB School, Korea University of Science and Technology (UST), Daejeon, South Korea
| | - Jinyoung Jeong
- KRIBB School, Korea University of Science and Technology (UST), Daejeon, South Korea; Environmental Disease Research Center, Korea Research Institute of Bioscience and Biotechnology (KRIBB), 125 Gwahak-ro, Yuseong-gu, Daejeon 34141, South Korea
| | - Won Kon Kim
- KRIBB School, Korea University of Science and Technology (UST), Daejeon, South Korea; Metabolic Regulation Research Center, Korea Research Institute of Bioscience and Biotechnology (KRIBB), 125 Gwahak-ro, Yuseong-gu, Daejeon 34141, South Korea
| | - Cho-Rok Jung
- KRIBB School, Korea University of Science and Technology (UST), Daejeon, South Korea; Stem Cell Convergence Research Center, Korea Research Institute of Bioscience and Biotechnology (KRIBB), 125 Gwahak-ro, Yuseong-gu, Daejeon 34141, South Korea
| | - Nam-Soon Kim
- Rare Disease Research Center, Korea Research Institute of Bioscience and Biotechnology (KRIBB), 125 Gwahak-ro, Yuseong-gu, Daejeon 34141, South Korea; KRIBB School, Korea University of Science and Technology (UST), Daejeon, South Korea
| | - Sung-Hee Cho
- Chemical Analysis Center, Korea Research Institute of Chemical Technology (KRICT), Daejeon 34114, South Korea.
| | - Da Yong Lee
- Rare Disease Research Center, Korea Research Institute of Bioscience and Biotechnology (KRIBB), 125 Gwahak-ro, Yuseong-gu, Daejeon 34141, South Korea; KRIBB School, Korea University of Science and Technology (UST), Daejeon, South Korea.
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Capobianco E, Pirrone I. Paternal programming of fetoplacental and offspring metabolic disorders. Placenta 2023; 141:71-77. [PMID: 37355440 DOI: 10.1016/j.placenta.2023.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 06/08/2023] [Accepted: 06/11/2023] [Indexed: 06/26/2023]
Abstract
The alarming increase in the prevalence of metabolic pathologies is of worldwide concern and has been linked not only to genetic factors but also to a large number of non-genetic factors. In recent years, there has been increasing interest in the study of the programming of metabolic diseases, such as type 2 diabetes mellitus (T2DM) and obesity, by paternal exposure, a paradigm termed "Paternal Origins of Health and Disease" (POHaD). This term derives from the better known "Developmental Origins of Health and Disease" (DOHaD), which focuses on the involvement of the maternal intrauterine environment and complications during pregnancy associated with the health and disease of the offspring. Studies on paternal programming have documented environmentally induced epigenetic modifications in the male germline and in seminal plasma, which lead to intergenerational and transgenerational phenotypes, evident already during fetoplacental development. Studies with animal models at both ends of the nutritional spectrum (undernutrition or overnutrition) have been performed to understand the possible mechanisms and signaling pathways leading to the programming of metabolic disorders by exploring epigenetic changes throughout the life of the offspring. The aim of this review was to address the evidence of the programming of fetoplacental developmental alterations and metabolic pathologies in the offspring of males with metabolic disorders and unhealthy exposures, highlighting the mechanisms involved in such programming and looking for paternal interventions to reduce negative health outcomes in the offspring.
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Affiliation(s)
- Evangelina Capobianco
- Universidad de Buenos Aires, Facultad de Medicina, Buenos Aires, Argentina; CONICET - Universidad de Buenos Aires, Laboratory of Reproduction and Metabolism, CEFYBO, Buenos Aires, Argentina.
| | - Irune Pirrone
- Universidad de Buenos Aires, Facultad de Medicina, Buenos Aires, Argentina; CONICET - Universidad de Buenos Aires, Laboratory of Reproduction and Metabolism, CEFYBO, Buenos Aires, Argentina
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Furse S, Koch H, Wright GA, Stevenson PC. Sterol and lipid metabolism in bees. Metabolomics 2023; 19:78. [PMID: 37644282 PMCID: PMC10465395 DOI: 10.1007/s11306-023-02039-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 07/27/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Bees provide essential pollination services for many food crops and are critical in supporting wild plant diversity. However, the dietary landscape of pollen food sources for social and solitary bees has changed because of agricultural intensification and habitat loss. For this reason, understanding the basic nutrient metabolism and meeting the nutritional needs of bees is becoming an urgent requirement for agriculture and conservation. We know that pollen is the principal source of dietary fat and sterols for pollinators, but a precise understanding of what the essential nutrients are and how much is needed is not yet clear. Sterols are key for producing the hormones that control development and may be present in cell membranes, where fatty-acid-containing species are important structural and signalling molecules (phospholipids) or to supply, store and distribute energy (glycerides). AIM OF THE REVIEW In this critical review, we examine the current general understanding of sterol and lipid metabolism of social and solitary bees from a variety of literature sources and discuss implications for bee health. KEY SCIENTIFIC CONCEPTS OF REVIEW We found that while eusocial bees are resilient to some dietary variation in sterol supply the scope for this is limited. The evidence of both de novo lipogenesis and a dietary need for particular fatty acids (FAs) shows that FA metabolism in insects is analogous to mammals but with distinct features. Bees rely on their dietary intake for essential sterols and lipids in a way that is dependent upon pollen availability.
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Affiliation(s)
- Samuel Furse
- Royal Botanic Gardens, Kew Green, Kew, Surrey, TW9 3AB, UK.
| | - Hauke Koch
- Royal Botanic Gardens, Kew Green, Kew, Surrey, TW9 3AB, UK
| | | | - Philip C Stevenson
- Royal Botanic Gardens, Kew Green, Kew, Surrey, TW9 3AB, UK.
- Natural Resources Institute, University of Greenwich, Chatham, Kent, ME4 4TB, UK.
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Shi Q, Qi K. Developmental origins of health and disease: Impact of paternal nutrition and lifestyle. Pediatr Investig 2023; 7:111-131. [PMID: 37324600 PMCID: PMC10262906 DOI: 10.1002/ped4.12367] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 01/29/2023] [Indexed: 09/20/2023] Open
Abstract
Most epidemiological and experimental studies have focused on maternal influences on offspring's health. The impact of maternal undernutrition, overnutrition, hypoxia, and stress is linked to adverse offspring outcomes across a range of systems including cardiometabolic, respiratory, endocrine, and reproduction among others. During the past decade, it has become evident that paternal environmental factors are also linked to the development of diseases in offspring. In this article, we aim to outline the current understanding of the impact of male health and environmental exposure on offspring development, health, and disease and explore the mechanisms underlying the paternal programming of offspring health. The available evidence suggests that poor paternal pre-conceptional nutrition and lifestyle, and advanced age can increase the risk of negative outcomes in offspring, via both direct (genetic/epigenetic) and indirect (maternal uterine environment) effects. Beginning at preconception, and during utero and the early life after birth, cells acquire an epigenetic memory of the early exposure which can be influential across the entire lifespan and program a child's health. Potentially not only mothers but also fathers should be advised that maintaining a healthy diet and lifestyle is important to improve offspring health as well as the parental health status. However, the evidence is mostly based on animal studies, and well-designed human studies are urgently needed to verify findings from animal data.
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Affiliation(s)
- Qiaoyu Shi
- Laboratory of Nutrition and Development, Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Pediatric Research Institute, Beijing Children's HospitalCapital Medical University, National Center for Children's HealthBeijingChina
| | - Kemin Qi
- Laboratory of Nutrition and Development, Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Pediatric Research Institute, Beijing Children's HospitalCapital Medical University, National Center for Children's HealthBeijingChina
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Abstract
Much evidence for diabetes mellitus being associated with dysregulated lipid metabolism has been accrued from studies using blood plasma. However, the systemic dysregulation these results point to is not understood. This study used Lipid Traffic Analysis on data from a mouse model of diabetes to test the hypothesis that the systemic control of lipid metabolism differed in a model of diabetes. This provided eidence for changes in the systemic control of both triglyceride and phospholipid metabolism that were not attributable to dietary intake. This supports the conclusion that diabetes is a systemic condition associated with dysregulated lipid metabolism through several pathways.
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Affiliation(s)
- Samuel Furse
- Core Metabolomics and Lipidomics Laboratory, Wellcome-MRC Institute of Metabolic Science, University of Cambridge, Addenbrooke's Treatment Centre, Keith Day Road Cambridge, Cambridge, CB2 0QQ, UK.
- Metabolic Disease Unit, Wellcome-MRC Institute of Metabolic Science, University of Cambridge, Addenbrooke's Treatment Centre, Keith Day Road Cambridge, Cambridge, CB2 0QQ, UK.
- Biological Chemistry Group, Jodrell Laboratory, Royal Botanic Gardens Kew, Richmond, TW9 3SD, UK.
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A mouse model of gestational diabetes shows dysregulated lipid metabolism post-weaning, after return to euglycaemia. Nutr Diabetes 2022; 12:8. [PMID: 35169132 PMCID: PMC8847647 DOI: 10.1038/s41387-022-00185-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 01/12/2022] [Accepted: 01/26/2022] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Gestational diabetes is associated with increased risk of type 2 diabetes mellitus and cardiovascular disease for the mother in the decade after delivery. However, the molecular mechanisms that drive these effects are unknown. Recent studies in humans have shown that lipid metabolism is dysregulated before diagnosis of and during gestational diabetes and we have shown previously that lipid metabolism is also altered in obese female mice before, during and after pregnancy. These observations led us to the hypothesis that this persistent dysregulation reflects an altered control of lipid distribution throughout the organism. METHODS We tested this in post-weaning (PW) dams using our established mouse model of obese GDM (high fat, high sugar, obesogenic diet) and an updated purpose-built computational tool for plotting the distribution of lipid variables throughout the maternal system (Lipid Traffic Analysis v2.3). RESULTS This network analysis showed that unlike hyperglycaemia, lipid distribution and traffic do not return to normal after pregnancy in obese mouse dams. A greater range of phosphatidylcholines was found throughout the lean compared to obese post-weaning dams. A range of triglycerides that were found in the hearts of lean post-weaning dams were only found in the livers of obese post-weaning dams and the abundance of odd-chain FA-containing lipids differed locally in the two groups. We have therefore shown that the control of lipid distribution changed for several metabolic pathways, with evidence for changes to the regulation of phospholipid biosynthesis and FA distribution, in a number of tissues. CONCLUSIONS We conclude that the control of lipid metabolism is altered following an obese pregnancy. These results support the hypothesis that obese dams that developed GDM maintain dysregulated lipid metabolism after pregnancy even when glycaemia returned to normal, and that these alterations could contribute to the increased risk of later type 2 diabetes and cardiovascular disease.
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