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Khadayat R, Bishwakarma M, Pant S, Bhatta OP, Bista PR, Kamar SB. Prevalence of metabolic syndrome in sickle cell disease patients: A cross-sectional study at a tertiary hospital in Nepal. EJHAEM 2024; 5:913-919. [PMID: 39415909 PMCID: PMC11474388 DOI: 10.1002/jha2.989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 07/13/2024] [Accepted: 07/16/2024] [Indexed: 10/19/2024]
Abstract
Background Sickle cell disease (SCD) is the most common hemoglobinopathy caused by an autosomal recessive genetic disorder leading to increased morbidity and mortality rates. SCD is prevalent in the Tharu community in the lowland (Terai) region of Nepal. Prevalence of metabolic syndrome among adults with SCD is poorly studied. Methodology This prospective cross-sectional study was conducted at Seti Provincial Hospital in Dhangadhi, Nepal, among 140 adolescents and adults with SCD, aged 15-60 years. Anthropometric and laboratory data were collected using an assisted questionnaire, and the SPSS software version 23 was used for data analysis. Descriptive and inferential statistics were used to summarize the presence of metabolic syndrome and were stratified in separate analyses by age and sex. National Cholesterol Education Program-Adult Treatment Panel III criteria were used to define metabolic syndrome. Aim This cross-sectional study aimed to assess the prevalence of metabolic syndrome among SCD patients with SCD registered at the Seti Provincial Hospital in Dhangadhi, Nepal. Results The prevalence of metabolic syndrome in the study participants was 7.8%. Our study revealed 5% of the patients overweight, and 1.4% obese. In this study, the mean triglyceride level was 118.5 mg/dL, and the mean high-density lipoprotein (HDL) level was 36.2 mg/dL (men) and 36.7 mg/dL (women). This study found that the mean fasting blood glucose level was 88.6 gm/dL. Similarly, 3.5% of patients had increased systolic blood pressure, and 7.8% had raised diastolic blood pressure. Study shows that changes in triglyceride level (p = 0.013), waist circumference, and HDL level (p = 0.0001 and 0.0048, respectively) are significantly associated with smoking or alcohol consumption; however, change in blood pressure (p = 0.013) and fasting blood sugar level (p = 0.086) are not associated with smoking or alcohol consumption. Conclusion Study concluded that though a lower proportion of SCD patients met the criteria for metabolic syndrome than in studies conducted in developed countries, it is crucial to consider metabolic syndrome while managing patients with SCD. Nevertheless, the authors advocate a more comprehensive study to draw significant conclusions.
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Affiliation(s)
- Ramesh Khadayat
- Patan Academic of Health SciencesPatan HospitalKathmanduNepal
| | | | | | - Om Prakash Bhatta
- Tribhuvan University Institute of Medicine Maharajgunj Medical CampusMaharajganjBagmatiNepal
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Wang M, Chen Z, Zhang Y. Serum Iron Levels, Dietary Iron Intake, and Supplement Use in Relation to Metabolic Syndrome in Adolescents: A Cross-Sectional Study. Biol Trace Elem Res 2024:10.1007/s12011-024-04152-1. [PMID: 38517678 DOI: 10.1007/s12011-024-04152-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 03/15/2024] [Indexed: 03/24/2024]
Abstract
The objective of this study was to investigate the potential associations between serum iron levels, dietary iron intake, and iron supplementation, and the prevalence of metabolic syndrome (MetS) in adolescents A cross-sectional analysis was conducted, utilizing data from adolescents participating in the 2003-2018 cycle of the National Health and Nutrition Examination Survey (NHANES). Odds ratios (ORs) and their corresponding 95% confidence intervals (CIs) pertaining to serum iron, dietary iron, and iron supplementation were derived through multivariate logistic regression models. Additionally, a restricted cubic spline (RCS) regression model was applied to explore the nonlinear relationship between dietary iron and serum iron concerning MetS. The study encompassed 4858 American adolescents aged 12 to 19, among whom 413 (8.5%) manifested MetS. The study cohort exhibited an average age of 15.52 years, comprising 2551 males (52.51%) and 2307 females (47.49%). Relative to individuals in the lowest serum iron quartile, those in the highest quartile for serum iron (OR = 0.33, 95% CI 0.21-0.50), the highest quartile for dietary iron (OR = 0.53, 95% CI 0.32-0.89), and those utilizing iron supplements (OR = 0.61, 95% CI 0.37-0.99) evinced a diminished prevalence of MetS, even post adjustment for potential confounding variables. A non-linear relationship was discerned between serum iron and MetS, exhibiting a statistically significant negative correlation when serum iron concentrations exceeded the inflection point (serum iron = 8.66 µmol/L, P for nonlinear < 0.001). This investigation reveals that higher levels of serum iron, increased dietary iron intake, and the use of iron supplements are linked to a lower prevalence of MetS in US adolescents. These findings suggest that dietary modifications could play a role in promoting the health of adolescents.
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Affiliation(s)
- Meng Wang
- Department of Pediatrics, The Third Affiliated Hospital of Shanghai University, Wenzhou, 325000, People's Republic of China
- Department of Pediatrics, Wenzhou People's Hospital, Wenzhou, 325000, People's Republic of China
- Department of Pediatrics, Wenzhou People's Hospital, Wenzhou Third Clinical Institute Affiliated to Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China
| | - Zhiyuan Chen
- Department of Pediatrics, The Third Affiliated Hospital of Shanghai University, Wenzhou, 325000, People's Republic of China.
- Department of Pediatrics, Wenzhou People's Hospital, Wenzhou, 325000, People's Republic of China.
- Department of Pediatrics, Wenzhou People's Hospital, Wenzhou Third Clinical Institute Affiliated to Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China.
| | - Yuanfeng Zhang
- Department of Urology, Shantou Central Hospital, Shantou, 515000, People's Republic of China
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3
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Ibemere SO, Oyedeji CI, Preiss L, Van Althuis LE, Hankins JS, Azul M, Burns EN, Glassberg J, Hagar W, Hussain F, King A, Melvin C, Myers J, Snyder A, Shah N, Tanabe P. Characterising the prevalence of overweight and obese status among adults with sickle cell disease. Br J Haematol 2023; 200:633-642. [PMID: 36382420 PMCID: PMC9957798 DOI: 10.1111/bjh.18548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 10/19/2022] [Accepted: 10/21/2022] [Indexed: 11/18/2022]
Abstract
Individuals with sickle cell disease (SCD) have historically been considered underweight. Despite increasing body mass index (BMI) in the general population, the prevalence of overweight and obese status remains unclear in the adult SCD population. Our primary aim was to determine the prevalence of overweight and obese status and to identify associations between BMI, demographic, and clinical characteristics. We conducted an analysis of abstracted electronic health record data and patient-reported outcomes from the Sickle Cell Disease Implementation Consortium registry; individuals aged 20-45 years were included. The median (interquartile range) BMI for the 1664 adults in this analysis was 23.9 (21.1-28) kg/m2 . In this cohort, 42.9% had a BMI of >25 kg/m2 (Centers for Disease Control and Prevention definition of overweight/obese). In multivariable analysis, higher odds of being overweight or obese were associated with female gender, older age, college education, private insurance, and hypertension diagnosis. Higher odds of a BMI of >25 kg/m2 were observed in individuals with HbSC or HbSβ+ thalassaemia regardless of hydroxycarbamide (hydroxyurea) exposure (odds ratio [OR] 3.4, p < 0.0001) and HbSS or HbSβ0 thalassaemia exposed to hydroxycarbamide (OR 1.6, p = 0.0003) compared to those with HbSS or HbSβ0 thalassaemia with no hydroxycarbamide exposure. These data highlight the importance of early identification, prevention, and intervention for increasing BMI to reduce obesity-related complications that may impact SCD-related complications.
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Affiliation(s)
| | - Charity I Oyedeji
- Department of Medicine, Division of Hematology, Duke University School of Medicine, Durham, North Carolina, USA
| | | | | | - Jane S Hankins
- St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Melissa Azul
- St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Ebony N Burns
- Duke University School of Nursing, Durham, North Carolina, USA
| | | | - Ward Hagar
- University of California San Francisco, San Francisco, California, USA
| | - Faiz Hussain
- University of Illinois at Chicago, Chicago, Illinois, USA
| | - Allison King
- Washington University in St. Louis, St. Louis, Missouri, USA
| | - Cathy Melvin
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - John Myers
- Duke University School of Nursing, Durham, North Carolina, USA
| | | | - Nirmish Shah
- Department of Medicine, Division of Hematology, Duke University School of Medicine, Durham, North Carolina, USA
- Duke University Hospital, Durham, North Carolina, USA
| | - Paula Tanabe
- Duke University School of Nursing and Medicine, Durham, North Carolina, USA
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Sachdev V, Tian X, Gu Y, Nichols J, Sidenko S, Li W, Beri A, Layne WA, Allen D, Wu CO, Thein SL. A phenotypic risk score for predicting mortality in sickle cell disease. Br J Haematol 2021; 192:932-941. [PMID: 33506990 PMCID: PMC9123430 DOI: 10.1111/bjh.17342] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 12/30/2020] [Indexed: 02/02/2023]
Abstract
Risk assessment for patients with sickle cell disease (SCD) remains challenging as it depends on an individual physician's experience and ability to integrate a variety of test results. We aimed to provide a new risk score that combines clinical, laboratory, and imaging data. In a prospective cohort of 600 adult patients with SCD, we assessed the relationship of 70 baseline covariates to all-cause mortality. Random survival forest and regularised Cox regression machine learning (ML) methods were used to select top predictors. Multivariable models and a risk score were developed and internally validated. Over a median follow-up of 4·3 years, 131 deaths were recorded. Multivariable models were developed using nine independent predictors of mortality: tricuspid regurgitant velocity, estimated right atrial pressure, mitral E velocity, left ventricular septal thickness, body mass index, blood urea nitrogen, alkaline phosphatase, heart rate and age. Our prognostic risk score had superior performance with a bias-corrected C-statistic of 0·763. Our model stratified patients into four groups with significantly different 4-year mortality rates (3%, 11%, 35% and 75% respectively). Using readily available variables from patients with SCD, we applied ML techniques to develop and validate a mortality risk scoring method that reflects the summation of cardiopulmonary, renal and liver end-organ damage. Trial Registration: ClinicalTrials.gov Identifier: NCT#00011648.
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Affiliation(s)
- Vandana Sachdev
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Xin Tian
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Yuan Gu
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - James Nichols
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Stanislav Sidenko
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Wen Li
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Andrea Beri
- Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - W. Austin Layne
- Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Darlene Allen
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Colin O. Wu
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Swee Lay Thein
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
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5
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Merlet AN, Féasson L, Bartolucci P, Hourdé C, Schwalm C, Gellen B, Galactéros F, Deldicque L, Francaux M, Messonnier LA. Muscle structural, energetic and functional benefits of endurance exercise training in sickle cell disease. Am J Hematol 2020; 95:1257-1268. [PMID: 32681734 DOI: 10.1002/ajh.25936] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 07/09/2020] [Accepted: 07/10/2020] [Indexed: 01/01/2023]
Abstract
Sickle cell disease (SCD) patients display skeletal muscle hypotrophy, altered oxidative capacity, exercise intolerance and poor quality of life. We previously demonstrated that moderate-intensity endurance training is beneficial for improving muscle function and quality of life of patients. The present study evaluated the effects of this moderate-intensity endurance training program on skeletal muscle structural and metabolic properties. Of the 40 randomized SCD patients, complete data sets were obtained from 33. The training group (n = 15) followed a personalized moderate-intensity endurance training program, while the non-training (n = 18) group maintained a normal lifestyle. Biopsies of the vastus lateralis muscle and submaximal incremental cycling tests were performed before and after the training program. Endurance training increased type I muscle fiber surface area (P = .038), oxidative enzyme activity [citrate synthase, P < .001; β-hydroxyacyl-CoA dehydrogenase, P = .009; type-I fiber cytochrome c oxidase, P = .042; respiratory chain complex IV, P = .017] and contents of respiratory chain complexes I (P = .049), III (P = .005), IV (P = .003) and V (P = .002). Respiratory frequency, respiratory exchange ratio, blood lactate concentration and rating of perceived exertion were all lower at a given submaximal power output after training vs non-training group (all P < .05). The muscle content of proteins involved in glucose transport and pH regulation were unchanged in the training group relative to the non-training group. The moderate-intensity endurance exercise program improved exercise capacity and muscle structural and oxidative properties. This trial was registered at www.clinicaltrials.gov as #NCT02571088.
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Affiliation(s)
- Angèle N. Merlet
- Laboratoire Interuniversitaire de Biologie de la Motricité Université de Lyon, Université Jean Monnet Saint‐Etienne France
| | - Léonard Féasson
- Laboratoire Interuniversitaire de Biologie de la Motricité Université de Lyon, Université Jean Monnet Saint‐Etienne France
- Unité de Myologie, Service de Physiologie Clinique et de l'Exercice Hôpital Universitaire de Saint‐Etienne Saint‐Etienne France
| | - Pablo Bartolucci
- Service de Médecine Interne Hôpital Henri‐Mondor (AP‐HP), Université Paris‐Est Créteil (UPEC) Créteil France
- Service de Santé Publique Hôpital Henri‐Mondor (AP‐HP), Université Paris‐Est Créteil Créteil France
| | - Christophe Hourdé
- Laboratoire Interuniversitaire de Biologie de la Motricité Université Savoie Mont Blanc Chambéry France
| | - Céline Schwalm
- Institute of Neuroscience Université Catholique de Louvain Louvain‐la‐Neuve Belgium
| | - Barnabas Gellen
- Service de Réhabilitation Cardiaque Hôpital Henri‐Mondor (Assistance Publique–Hôpitaux de Paris [APHP]) Créteil France
| | - Frédéric Galactéros
- Service de Santé Publique Hôpital Henri‐Mondor (AP‐HP), Université Paris‐Est Créteil Créteil France
- Laboratoire Interuniversitaire de Biologie de la Motricité Université Savoie Mont Blanc Chambéry France
| | - Louise Deldicque
- Institute of Neuroscience Université Catholique de Louvain Louvain‐la‐Neuve Belgium
| | - Marc Francaux
- Institute of Neuroscience Université Catholique de Louvain Louvain‐la‐Neuve Belgium
| | - Laurent A. Messonnier
- Laboratoire Interuniversitaire de Biologie de la Motricité Université Savoie Mont Blanc Chambéry France
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McLean A, Wright F, deJong N, Skinner S, Loughlin CE, Levenson A, Carden MA. Hemoglobin A 1c and fructosamine correlate in a patient with sickle cell disease and diabetes on chronic transfusion therapy. Pediatr Blood Cancer 2020; 67:e28499. [PMID: 32618413 PMCID: PMC7674195 DOI: 10.1002/pbc.28499] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 05/27/2020] [Accepted: 05/28/2020] [Indexed: 12/11/2022]
Abstract
In patients with sickle cell disease (SCD) and diabetes mellitus (DM), hemoglobin A1c (HbA1c ) is unreliable and the American Diabetes Association recommends monitoring long-term glycemia by measuring serum glucose, but use of serum fructosamine (SF), a measurement independent of red cell lifespan, has been reported. SF as a screen for DM in SCD, however, is not standardized and its relationship to serum glucose has not been validated. Further, screening for DM was not adequately addressed in the 2014 National Heart, Lung, and Blood Institute (NHLBI) guidelines for SCD management. Blood transfusions, an important treatment for some patients with SCD, can also impact HbA1c . We present a case of a patient with SCD and cystic fibrosis-related diabetes on monthly chronic transfusions therapy (CTT) who had well-correlated "steady state" HbA1c and SF levels over time, suggesting for the first time these markers may actually be useful when following long-term glycemic control in patients with SCD on CTT programs.
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Affiliation(s)
- Ashley McLean
- University of North Carolina School of Medicine, Chapel
Hill, North Carolina
| | - Frances Wright
- University of North Carolina School of Medicine, Chapel
Hill, North Carolina,Department of Pediatrics, Division of Pediatric
Hematology/Oncology, University of North Carolina School of Medicine, Chapel Hill,
North Carolina
| | - Neal deJong
- University of North Carolina School of Medicine, Chapel
Hill, North Carolina,Department of Pediatrics, Division of General Pediatrics
and Adolescent Medicine, University of North Carolina School of Medicine, Chapel
Hill, North Carolina
| | - Sarah Skinner
- University of North Carolina School of Medicine, Chapel
Hill, North Carolina,Department of Medicine, Division of Hematology, University
of North Carolina School of Medicine, Chapel Hill, North Carolina,University of North Carolina Blood Research Center, Chapel
Hill, North Carolina
| | - Ceila E. Loughlin
- University of North Carolina School of Medicine, Chapel
Hill, North Carolina,Department of Pediatrics, Division of Pediatric
Pulmonology, University of North Carolina School of Medicine, Chapel Hill, North
Carolina
| | - Amy Levenson
- University of North Carolina School of Medicine, Chapel
Hill, North Carolina,Department of Pediatrics, Division of Pediatric
Endocrinology and Diabetes, University of North Carolina School of Medicine, Chapel
Hill, North Carolina
| | - Marcus A. Carden
- University of North Carolina School of Medicine, Chapel
Hill, North Carolina,Department of Pediatrics, Division of Pediatric
Hematology/Oncology, University of North Carolina School of Medicine, Chapel Hill,
North Carolina,Department of Medicine, Division of Hematology, University
of North Carolina School of Medicine, Chapel Hill, North Carolina,University of North Carolina Blood Research Center, Chapel
Hill, North Carolina
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7
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Wood KC, Gladwin MT, Straub AC. Sickle cell disease: at the crossroads of pulmonary hypertension and diastolic heart failure. Heart 2019; 106:562-568. [DOI: 10.1136/heartjnl-2019-314810] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 11/22/2019] [Accepted: 11/25/2019] [Indexed: 12/31/2022] Open
Abstract
Sickle cell disease (SCD) is caused by a single point mutation in the gene that codes for beta globin synthesis, causing haemoglobin polymerisation, red blood cell stiffening and haemolysis under low oxygen and pH conditions. Downstream effects include widespread vasculopathy due to recurring vaso-occlusive events and haemolytic anaemia, affecting all organ systems. Cardiopulmonary complications are the leading cause of death in patients with SCD, primarily resulting from diastolic heart failure (HF) and/or pulmonary hypertension (PH). HF in SCD often features biventricular cardiac hypertrophy and left ventricular (LV) diastolic dysfunction. Among HF cases in the general population, approximately half occur with preserved ejection fraction (HFpEF). The insidious evolution of HFpEF differs from the relatively acute evolution of HF with reduced ejection fraction. The PH of SCD has diverse origins, which can be pulmonary arterial (precapillary), pulmonary venous (postcapillary) or pulmonary thromboembolic. It is also appreciated that patients with SCD can develop both precapillary and postcapillary PH, with elevations in LV diastolic pressures, as well as elevations in transpulmonary pressure gradient and pulmonary vascular resistance. Regardless of the cause of PH in SCD, its presence significantly reduces functional capacity and increases mortality. PH that occurs in the presence of HFpEF is usually of postcapillary origin. This review aims to assemble what has been learnt from clinical and animal studies about the manifestation of PH-HFpEF in SCD, specifically the contributions of LV diastolic dysfunction and myocardial fibrosis, in an attempt to gain an understanding of its evolution.
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Acacia Senegal (Gum Arabic) Supplementation Modulate Lipid Profile and Ameliorated Dyslipidemia among Sickle Cell Anemia Patients. J Lipids 2019; 2019:3129461. [PMID: 31316836 PMCID: PMC6604417 DOI: 10.1155/2019/3129461] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 05/18/2019] [Accepted: 06/02/2019] [Indexed: 02/07/2023] Open
Abstract
Background Sickle cell disease (SCD) is an inherited haemolytic anemia with a variable course and severity. Knowledge of prognostic biomarkers may help in the establishment of therapeutic intervention, management, and follow-up of patients. There have been scattered reports of low high-density lipoprotein cholesterol (HDL-C) and increased triglyceride (TG) in SCD patients. In addition, TG levels have been suggested to be elevated in patients with increased endothelial activation. An increased TG level has been associated with haemolysis, vascular dysfunction, and increased prevalence of pulmonary hypertension. Gum Arabic (GA) is an edible, dried, gummy exudate from the acacia Senegal tree. Several studies on GA ingestion have shown reduced plasma cholesterol and low-density lipoprotein (LDL) concentrations in both animals and humans. We investigated GA's therapeutic potential to modulate serum lipids in patients with sickle cell anemia. Methods This study recruited and documented secondary outcomes in 47 patients (aged 5–42 years) carrying hemoglobin SS. The patients received 30 g/day of GA for 12 weeks. Total cholesterol, TG, LDL, and HDL were measured before and after GA intake. Cobas C311 (Roche, Germany) automated chemistry analyser was used for direct determination of the values of the lipid profile. Results GA significantly decreased total cholesterol (TC), TG, and LDL (p = 0.006, 0.04, and 0.02, resp.). GA showed no effect on HDL level. Baseline serum TG and LDL correlated significantly with the hydrogen peroxide (H2O2) level, which is known as an oxidative stress marker (p = 0.003 and 0.04, resp.). None of the lipid profile elements correlated with age. Conclusion Our results revealed that dyslipidemia in sickle cell patients is associated with oxidative stress but not associated with age. The findings showed that GA significantly decreased TC, LDL, and TG levels, revealing a novel effect of GA, which is considered a natural dietary fibre that can modulate lipid profile in patients with sickle cell anemia. Trial Registration This retrospective trial is registered with ClinicalTrials.gov Identifier: NCT02467257 on 3 June, 2015.
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