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Chen H, Wang J, Zheng B, Xia W, Tan G, Wu H, Wang Y, Deng Z, Wang Y, Zhang J, Zhang H. Association of serum fatty acid pattern with depression in U.S. adults: analysis of NHANES 2011-2012. Lipids Health Dis 2024; 23:177. [PMID: 38851716 PMCID: PMC11161977 DOI: 10.1186/s12944-024-02142-9] [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: 01/30/2024] [Accepted: 05/11/2024] [Indexed: 06/10/2024] Open
Abstract
BACKGROUND Exposure to different concentration levels of fatty acids (FAs) may have an impact on depression. However, previous studies using individual FAs may not reflect the performance of mixtures of various FAs, and the associations of FA patterns with depression remain unclear. METHODS We conducted the cross-sectional analysis in 792 adults aged 18 and older with available serum FAs and depression screening data in the National Health and Nutrition Examination Survey (NHANES) 2011-2012. The serum concentrations of thirty FAs were measured using gas chromatography-mass spectrometry and their percentage compositions were subsequently calculated. Depression was defined as the Patient Health Questionnaire-9 score ≥ 10. We employed principal component analysis to derive serum FA patterns. We examined the association between these patterns and depression in the overall population and various subgroups through survey-weighted logistic regression. RESULTS Four distinct patterns of serum FAs were identified: 'high eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA); low docosatetraenoic acid (DTA) and docosapentaenoic acid (DPA) n-6', 'high long-chain saturated FA and long chain FA', 'low median-chain saturated FA and myristoleic acid' and 'low capric acid and lauric acid; high gamma-linolenic acid (GLA) and stearidonic acid (SDA)' pattern. Individuals in the high tertile of 'high EPA and DHA; low DTA and DPA n-6' pattern score had 0.46 (95% CI: 0.22, 0.93) lower odds of developing depression compared to individuals in the lowest tertile after adjusting for confounders such as age, sex, physical activity and total energy intake, etc. The odds ratio (OR) of depression was increased in the population with the highest tertile of 'low capric acid and lauric acid; high GLA and SDA' pattern (OR: 2.45, 95% CI: 1.24, 4.83). In subgroup analyses, we observed that the association between 'high EPA and DHA; low DTA and DPA n-6' and depression persisted among specific demographic and lifestyle subgroups, including females, non-Mexican Americans, non-obese, those aged over 60 years, smokers and drinkers. Similarly, 'low capric acid and lauric acid; high GLA and SDA' showed stable associations in female, non-Mexican Americans and smokers. CONCLUSIONS Serum FA patterns are associated with depression, and their relationships vary across sex, race, BMI, age, smoking and drinking subgroups, highlighting the importance of considering specific FA patterns within these demographic and lifestyle categories. Utilization of combined FA administration may serve as a mitigation measure against depression in these specific populations.
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Affiliation(s)
- Hengying Chen
- Department of Maternal and Child Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Jue Wang
- Huadu District Center for Disease Control and Prevention, Guangzhou, Guangdong, China
| | - Baohua Zheng
- Department of Maternal and Child Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Wenqi Xia
- Department of Maternal and Child Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Gongjun Tan
- Department of Clinical Laboratory, Zhuhai Center for Maternal and Child Health Care, Zhuhai, Guangdong, China
| | - Hongyuan Wu
- Department of Child Health, Zhuhai Center for Maternal and Child Health Care, Zhuhai, Guangdong, China
| | - Yao Wang
- Postnatal Care Center (Department of Postpartum Rehabilitation), Zhuhai Center for Maternal and Child Health Care, Zhuhai, Guangdong, China
| | - Zhen Deng
- Department of Clinical Laboratory, Zhuhai Center for Maternal and Child Health Care, Zhuhai, Guangdong, China
| | - Yiyuan Wang
- Department of Child Health, Zhuhai Center for Maternal and Child Health Care, Zhuhai, Guangdong, China
| | - Jianduan Zhang
- Department of Maternal and Child Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.
- Key Laboratory of Environment and Health, Ministry of Education & Ministry of Environmental Protection, State Key Laboratory of Environmental Health (Incubation), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.
| | - Hongzhong Zhang
- Zhuhai Center for Maternal and Child Health Care, Zhuhai, Guangdong, China.
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Zhang Y, Sun Y, Yu Q, Song S, Brenna JT, Shen Y, Ye K. Higher ratio of plasma omega-6/omega-3 fatty acids is associated with greater risk of all-cause, cancer, and cardiovascular mortality: A population-based cohort study in UK Biobank. eLife 2024; 12:RP90132. [PMID: 38578269 PMCID: PMC10997328 DOI: 10.7554/elife.90132] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024] Open
Abstract
Background Circulating omega-3 and omega-6 polyunsaturated fatty acids (PUFAs) have been associated with various chronic diseases and mortality, but results are conflicting. Few studies examined the role of omega-6/omega-3 ratio in mortality. Methods We investigated plasma omega-3 and omega-6 PUFAs and their ratio in relation to all-cause and cause-specific mortality in a large prospective cohort, the UK Biobank. Of 85,425 participants who had complete information on circulating PUFAs, 6461 died during follow-up, including 2794 from cancer and 1668 from cardiovascular disease (CVD). Associations were estimated by multivariable Cox proportional hazards regression with adjustment for relevant risk factors. Results Risk for all three mortality outcomes increased as the ratio of omega-6/omega-3 PUFAs increased (all Ptrend <0.05). Comparing the highest to the lowest quintiles, individuals had 26% (95% CI, 15-38%) higher total mortality, 14% (95% CI, 0-31%) higher cancer mortality, and 31% (95% CI, 10-55%) higher CVD mortality. Moreover, omega-3 and omega-6 PUFAs in plasma were all inversely associated with all-cause, cancer, and CVD mortality, with omega-3 showing stronger effects. Conclusions Using a population-based cohort in UK Biobank, our study revealed a strong association between the ratio of circulating omega-6/omega-3 PUFAs and the risk of all-cause, cancer, and CVD mortality. Funding Research reported in this publication was supported by the National Institute of General Medical Sciences of the National Institute of Health under the award number R35GM143060 (KY). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
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Affiliation(s)
- Yuchen Zhang
- Department of Epidemiology and Biostatistics, College of Public Health, University of GeorgiaAthens, GeorgiaUnited States
| | - Yitang Sun
- Department of Genetics, University of GeorgiaAthens, GeorgiaUnited States
| | - Qi Yu
- Department of Biostatistics and Bioinformatics, Emory UniversityAtlanta, GeorgiaUnited States
| | - Suhang Song
- Department of Health Policy and Management, College of Public Health, University of GeorgiaAthens, GeorgiaUnited States
| | - J Thomas Brenna
- Division of Nutritional Sciences, Cornell UniversityIthaca, New YorkUnited States
- Dell Pediatric Research Institute and the Depts of Pediatrics, of Nutrition, and of Chemistry, University of Texas at AustinAustin, TexasUnited States
| | - Ye Shen
- Department of Epidemiology and Biostatistics, College of Public Health, University of GeorgiaAthens, GeorgiaUnited States
| | - Kaixiong Ye
- Department of Genetics, University of GeorgiaAthens, GeorgiaUnited States
- Institute of Bioinformatics, University of GeorgiaAthens, GeorgiaUnited States
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Batista ANR, Garcia T, Prudente R, Barbosa MF, Modesto P, Franco E, de Godoy I, Paiva S, Azevedo P, Tanni SE. Cardiac function, myocardial fat deposition, and lipid profile in young smokers: a cross-sectional study. Front Cardiovasc Med 2023; 10:1225621. [PMID: 38034384 PMCID: PMC10682099 DOI: 10.3389/fcvm.2023.1225621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 10/26/2023] [Indexed: 12/02/2023] Open
Abstract
Background There is a possibility that cardiac morphometric characteristics are associated with the lipid profile, that is, the composition and concentration of triglycerides, total cholesterol, HDL, LDL, and others lipoproteins in young smokers without comorbidities. Thus, this study aimed to evaluate the association of cardiac morphometric characteristics, myocardial fat deposition, and smoking cessation with the lipid profile of young smokers. Methods A clinical and laboratory evaluation of lipids and the smoking status was performed on 57 individuals, including both a smoker group and a control group. Cardiac magnetic resonance imaging (MRI) with proton spectroscopy was performed to identify cardiac changes and triglyceride (TG) deposition in myocardial tissue. Results No differences were observed between the groups (control vs. smokers) in relation to the amount of myocardial TG deposition (p = 0.47); however, when TG deposition was correlated with cardiac MRI variables, a positive correlation was identified between smoking history and myocardial TG deposition [hazard ratio (95% CI), 0.07 (0.03-0.12); p = 0.002]. Furthermore, it was observed that the smoking group had lower high-density lipoprotein cholesterol [51 (45.5-59.5) mg/dl vs. 43 (36-49.5) mg/dl, p = 0.003] and higher TG [73 (58-110) mg/dl vs. 122 (73.5-133) mg/dl, p = 0.01] and very-low-density lipoprotein cholesterol [14.6 (11.6-22.2) mg/dl vs. 24.4 (14.7-26.6) mg/dl, p = 0.01] values. In the control and smoking groups, a negative correlation between TGs and the diameter of the aortic root lumen and positive correlation with the thickness of the interventricular septum and end-diastolic volume (EDV) of both the right ventricle (RV) and left ventricle (LV) were noted. Moreover, in the RV, positive correlations with the end-systolic volume (ESV) index (ESVI), stroke volume (SV), ESV, and EDV were observed. Regarding serum free fatty acids, we found a negative correlation between their values and the diameter of the lumen of the ascending aortic vessel. Lipoprotein lipase showed a positive correlation with the SV index of the RV and negative correlation with the diameter of the lumen of the ascending aortic vessel. Conclusion Several associations were observed regarding cardiac morphometric characteristics, myocardial fat deposition, and smoking cessation with the lipid profile of young smokers.
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Affiliation(s)
- Ana Natália Ribeiro Batista
- Pneumology Area, Department of Internal Medicine, Botucatu School of Medicine, São Paulo State University (UNESP), Botucatu, Brazil
| | - Thaís Garcia
- Pneumology Area, Department of Internal Medicine, Botucatu School of Medicine, São Paulo State University (UNESP), Botucatu, Brazil
| | - Robson Prudente
- Pulmonary Function Laboratory, Clinical Hospital of Botucatu Medical School, São Paulo State University (UNESP), Botucatu, Brazil
| | - Maurício F. Barbosa
- Department of Tropical Diseases and Diagnostic Imaging, Botucatu School of Medicine, São Paulo State University (UNESP), Botucatu, Brazil
| | - Pamela Modesto
- Pneumology Area, Department of Internal Medicine, Botucatu School of Medicine, São Paulo State University (UNESP), Botucatu, Brazil
| | - Estefânia Franco
- Pulmonary Function Laboratory, Clinical Hospital of Botucatu Medical School, São Paulo State University (UNESP), Botucatu, Brazil
| | - Irma de Godoy
- Pneumology Area, Department of Internal Medicine, Botucatu School of Medicine, São Paulo State University (UNESP), Botucatu, Brazil
| | - Sergio Paiva
- Pneumology Area, Department of Internal Medicine, Botucatu School of Medicine, São Paulo State University (UNESP), Botucatu, Brazil
| | - Paula Azevedo
- Pneumology Area, Department of Internal Medicine, Botucatu School of Medicine, São Paulo State University (UNESP), Botucatu, Brazil
| | - Suzana Erico Tanni
- Pneumology Area, Department of Internal Medicine, Botucatu School of Medicine, São Paulo State University (UNESP), Botucatu, Brazil
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Murff HJ, Greevy RA, Sternlieb S, Gilliam K, King S, Sanghani R, Tindle HA. The Fish Oil to Reduce Tobacco Use iN Expectant mothers (FORTUNE) feasibility trial. Am J Obstet Gynecol MFM 2022; 4:100707. [PMID: 35948268 DOI: 10.1016/j.ajogmf.2022.100707] [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: 06/13/2022] [Revised: 08/03/2022] [Accepted: 08/04/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Three small clinical trials have suggested that supplementation with n-3 long-chain polyunsaturated fatty acids (eicosapentaenoic acid and docosahexaenoic acid) found in fish oils may reduce nicotine cravings and at higher doses reduce cigarette consumption. Pregnant women who smoke have fewer pharmacologic options to aid them with smoking cessation. Although n-3 long-chain polyunsaturated fatty acid supplementation has been studied in pregnancy, few studies have evaluated doses of ≥4 g per day, and no previous studies have selectively enrolled pregnant women who smoke. High-dose n-3 long-chain polyunsaturated fatty acids may aid cessation but could be poorly tolerated in pregnant women who smoke because of gastrointestinal side effects. OBJECTIVE We conducted a feasibility trial to determine the tolerability of high-dose n-3 long-chain polyunsaturated fatty acid supplementation in pregnant women who smoked. We hypothesized that n-3 long-chain polyunsaturated fatty acid doses of 4.2 g a day would be well-tolerated relative to an olive oil placebo. We assessed red blood cell phospholipid membrane concentrations at baseline and end of therapy (4 weeks) and piloted outcomes for a future efficacy trial of n-3 long-chain polyunsaturated fatty acid supplementation for smoking cessation in pregnancy. STUDY DESIGN We recruited 28 pregnant women between the gestational ages of 6 and 36 weeks who reported daily cigarette smoking and were motivated to quit to participate in a double-blind placebo-controlled randomized feasibility trial of 4.2 g per day of n-3 long-chain polyunsaturated fatty acid supplementation. Participants reported cigarettes per day, completed the Fagerström Test for Cigarette Dependence, and provided blood, urine, and exhaled CO samples. We used repeated-measures analysis of variance to pilot analyses of changes in cigarettes per day and Fagerström Test for Cigarette Dependence scores. RESULTS At baseline, red blood cell membrane eicosapentaenoic acid concentrations were negatively correlated with cigarettes per day (r=-0.44; P=.04). By 4 weeks, circulating n-3 long-chain polyunsaturated fatty acid levels increased by 18% in the n-3 long-chain polyunsaturated fatty acid supplementation arm vs a decrease of 3% in the placebo arm. Occurrence of gastrointestinal side effects such as burping, heartburn, diarrhea, abdominal pain, or nausea did not differ statistically between study arms. At 4 weeks, participants allocated to the n-3 long-chain polyunsaturated fatty acids arm reported a median of 3 cigarettes per day (interquartile range, 1-8) vs 7 cigarettes per day (interquartile range, 1-14) in the placebo arm, which was not statistically significant (P=.99). Participants allocated to the n-3 long-chain polyunsaturated fatty acids arm had a decrease of 1 (interquartile range, 0-1) on the Fagerström Test for Cigarette Dependence score vs 0 (interquartile range, 0-0) for placebo (P=.46). CONCLUSION High-dose n-3 long-chain polyunsaturated fatty acids may be tolerated in pregnant women who smoke; however, there was a high level of participant dropout, with more participants allocated to the fish oil arm becoming lost to follow-up. These results will inform the design of a future large-scale randomized controlled trial to test the impact of fish oil supplements on smoking cessation in pregnancy.
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Affiliation(s)
- Harvey J Murff
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN (Drs Murff and Sternlieb, Ms Gilliam, Mr King, and Dr Tindle); Geriatric Research, Education, and Clinical Centers, United States Department of Veterans Affairs, VA Tennessee Valley Healthcare System, Nashville, TN (Drs Murff and Tindle); Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN (Drs Murff and Tindle).
| | - Robert A Greevy
- Departments of Biostatistics (Dr Greevy), Vanderbilt University Medical Center, Nashville, TN
| | - Sarah Sternlieb
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN (Drs Murff and Sternlieb, Ms Gilliam, Mr King, and Dr Tindle)
| | - Karen Gilliam
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN (Drs Murff and Sternlieb, Ms Gilliam, Mr King, and Dr Tindle)
| | - Stephen King
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN (Drs Murff and Sternlieb, Ms Gilliam, Mr King, and Dr Tindle)
| | - Reesha Sanghani
- Departments of Obstetrics and Gynecology (Dr Sanghani), Vanderbilt University Medical Center, Nashville, TN
| | - Hilary A Tindle
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN (Drs Murff and Sternlieb, Ms Gilliam, Mr King, and Dr Tindle); Geriatric Research, Education, and Clinical Centers, United States Department of Veterans Affairs, VA Tennessee Valley Healthcare System, Nashville, TN (Drs Murff and Tindle); Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN (Drs Murff and Tindle)
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5
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Murff HJ, Greevy RA, Sanghani RS, Hartmann KE, Hartert TV, Graves CR, Lee SS, Tindle HA. Investigating N-3 Fatty Acids to prevent Neonatal Tobacco-related outcomeS (INFANTS): study protocol for a double-blind, randomized, placebo-controlled parallel clinical trial of n-3 polyunsaturated fatty acids in pregnant smokers. Trials 2021; 22:922. [PMID: 34906201 PMCID: PMC8669400 DOI: 10.1186/s13063-021-05865-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 11/23/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Tobacco use during pregnancy is the most important modifiable risk factor associated with adverse pregnancy outcomes, increasing the risk of preterm birth, intrauterine growth restriction and sudden infant death syndrome. Fewer than half of pregnant smokers can quit on their own. Identifying safe and effective therapies to prevent tobacco-related adverse pregnancy outcomes and/or increase smoking cessation in pregnant women would have a substantial public health impact. Cigarette smoking is associated with a relative deficiency in circulating n-3 long-chain polyunsaturated fatty acid (n-3 LCPUFA) levels. A recent analysis found that smokers taking n-3 LCPUFAs during pregnancy had a reduction in preterm labor risk when compared to non-smokers. Studies have shown that supplemental n-3 LCPUFAs may also reduce nicotine cravings and daily cigarette use. Thus, smokers may benefit from supplemental n-3 LCPUFAs by lowering the risk of preterm labor and/or increased smoking cessation. To address important remaining knowledge gaps, we propose the Investigating N-3 Fatty Acids to prevent Neonatal Tobacco related outcomeS (INFANTS). METHODS The INFANTS study is a multicenter, randomized, double-blind, placebo-controlled study that will randomize 400 pregnant smokers to either supplemental n-3 LCPUFAs or placebo. Participants will be enrolled between 12 and 24 weeks' gestation and followed until 6 weeks after delivery. We will recruit from clinical centers throughout Middle Tennessee. We will assess smoking behavior after 12 weeks of supplementation using self-report and validated biomarkers of tobacco exposure. We will measure response to supplementation using biological markers of n-3 LCPUFA status. Our primary endpoint will be preterm labor as reflected by gestational age at delivery. Our secondary endpoint will be change from baseline in cigarettes per day at 12 weeks. DISCUSSION This study tests the hypothesis that smoking-induced n-3 LCPUFA deficiencies contribute to tobacco-related adverse pregnancy outcomes and that supplementation of n-3 LCPUFAs in pregnant smokers may prevent these complications. If our study demonstrates that supplemental n-3 LCPUFAs are effective at reducing the risk of tobacco-related adverse neonatal outcomes and/or reducing tobacco use during pregnancy, our results could have an immediate and major impact on pregnancy care and neonatal outcomes. TRIAL REGISTRATION ClinicalTrials.gov NCT04417595. Registered on April 21, 2020.
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Affiliation(s)
- Harvey J Murff
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 450, Nashville, TN, 37232, USA.
- Geriatric Research, Education and Clinical Center, Tennessee Valley Healthcare System, Nashville, TN, USA.
| | - Robert A Greevy
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, USA
| | - Reesha S Sanghani
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, USA
| | - Katherine E Hartmann
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, USA
| | - Tina V Hartert
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, USA
| | | | - Scott S Lee
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 450, Nashville, TN, 37232, USA
| | - Hilary A Tindle
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 450, Nashville, TN, 37232, USA
- Geriatric Research, Education and Clinical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
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McLaverty A, Allott KA, Berger M, Hester R, McGorry PD, Nelson B, Markulev C, Yuen HP, Schäfer MR, Mossaheb N, Schlögelhofer M, Smesny S, Hickie IB, Berger GE, Chen EYH, de Haan L, Nieman DH, Nordentoft M, Riecher-Rössler A, Verma S, Thompson A, Yung AR, Amminger GP. Omega-3 fatty acids and neurocognitive ability in young people at ultra-high risk for psychosis. Early Interv Psychiatry 2021; 15:874-881. [PMID: 32893462 DOI: 10.1111/eip.13025] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 07/03/2020] [Accepted: 07/05/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Neurocognitive impairments are core early features of psychosis and are observed in those at ultra-high risk (UHR) for psychosis. The aim of the present study was to explore whether neurocognition is associated with polyunsaturated fatty acids (PUFAs), as has been observed in other clinical populations. METHOD Erythrocyte levels of total omega-3-and omega-6 PUFAs the omega-3/omega-6 ratio, were measured in 265 UHR individuals. Six domains of neurocognition as well a Composite Score, were assessed using the Brief Assessment of Cognition in Schizophrenia. Pearson's correlations were used to assess the relationship between PUFAs and neurocognition. All analyses were controlled for tobacco smoking. RESULTS Verbal Fluency correlated positively with eicosapentaenoic acid (P = .024) and alpha-linolenic acid (P = .01), and negatively with docosahexanoic acid (P = .007) and Working Memory positively correlated with omega-3/omega-6 ratio (P = .007). CONCLUSIONS The current results provide support for a relationship between Verbal Fluency and omega-3 PUFAs in UHR. Further investigation is required to elucidate whether these biomarkers are useful as risk markers or in understanding the biological underpinning of neurocognitive impairment in this population.
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Affiliation(s)
- Alison McLaverty
- Melbourne School of Psychological Sciences, The University of Melbourne, Parkville, Australia
| | - Kelly A Allott
- Orygen, The National Centre of Excellence in Youth Mental Health, Parkville, Australia.,The Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia
| | - Maximus Berger
- Orygen, The National Centre of Excellence in Youth Mental Health, Parkville, Australia.,The Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia
| | - Rob Hester
- Melbourne School of Psychological Sciences, The University of Melbourne, Parkville, Australia
| | - Patrick D McGorry
- Orygen, The National Centre of Excellence in Youth Mental Health, Parkville, Australia.,The Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia
| | - Barnaby Nelson
- Orygen, The National Centre of Excellence in Youth Mental Health, Parkville, Australia.,The Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia
| | - Connie Markulev
- Orygen, The National Centre of Excellence in Youth Mental Health, Parkville, Australia.,The Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia
| | - Hok Pan Yuen
- Orygen, The National Centre of Excellence in Youth Mental Health, Parkville, Australia.,The Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia
| | - Miriam R Schäfer
- Orygen, The National Centre of Excellence in Youth Mental Health, Parkville, Australia.,Department of Child and Adolescent Psychiatry, Medical University Vienna, Vienna, Austria
| | - Nilufar Mossaheb
- Department of Child and Adolescent Psychiatry, Medical University Vienna, Vienna, Austria
| | - Monika Schlögelhofer
- Department of Child and Adolescent Psychiatry, Medical University Vienna, Vienna, Austria
| | - Stefan Smesny
- Department of Psychiatry, University Hospital Jena, Jena, Germany
| | - Ian B Hickie
- Brain and Mind Centre, University of Sydney, Sydney, Australia
| | - Gregor Emanuel Berger
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Hospital of Psychiatry Zurich, University of Zurich, Zurich, Switzerland
| | - Eric Y H Chen
- Department of Psychiatry, University of Hong Kong, Hong Kong, Hong Kong
| | - Lieuwe de Haan
- Department of Psychiatry, Amsterdam University Medical Centers (location AMC), Amsterdam, The Netherlands
| | - Dorien H Nieman
- Department of Psychiatry, Amsterdam University Medical Centers (location AMC), Amsterdam, The Netherlands
| | | | | | - Swapna Verma
- Institute of Mental Health, Singapore, Singapore
| | - Andrew Thompson
- Orygen, The National Centre of Excellence in Youth Mental Health, Parkville, Australia.,The Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia
| | - Alison Ruth Yung
- Orygen, The National Centre of Excellence in Youth Mental Health, Parkville, Australia.,The Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia
| | - G Paul Amminger
- Orygen, The National Centre of Excellence in Youth Mental Health, Parkville, Australia.,The Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia
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7
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[Nutritional problems in smokers and passive smokers]. NUTR HOSP 2021; 38:31-34. [PMID: 34323092 DOI: 10.20960/nh.03794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
OBJECTIVE active or passive tobacco use affects a high percentage of individuals and is associated with various health risks. The aim of this review was to look more closely at the nutritional problems that are specific of smokers, which may harm their health. METHODS a bibliographic search related to the topic. RESULTS smokers consume lower amounts of various foods, especially fruits, vegetables, cereals and dairy. As a result, their intake of vitamins, minerals, and phytochemicals is lower than that observed in non-smokers. Their consumption of meat, caffeine and alcohol is usually higher, and their activity lower than those of non-smokers, coexisting in smokers unhealthy behaviors that contribute to harming their health and quality of life. Oxidative stress and metabolic changes render the needs for some nutrients higher in smokers to achieve the same biochemical situation as in non-smokers. Recommended intakes of vitamin C have increased, but it will probably be necessary to also increase the intakes of other nutrients. In general, smokers suffer from deficiencies more frequently (vitamins C, E, β-carotene, B1, B2, B12, folic acid, calcium, magnesium, iron, iodine, etc.) than non-smokers. Passive smokers are also affected in their eating habits and nutritional status. CONCLUSIONS the worse nutritional status of smokers can contribute to the appearance/worsening of various diseases associated with smoking (cardiovascular, cancer, cataracts, osteoporosis, etc.); therefore, nutritional surveillance and correction of nutritional deficiencies could represents health benefits for smokers and passive smokers, which should be considered in the future.
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Wheeler E, Walsh-Wilcox M, Shah M, Achrekar A, Anderson JR, Walker MK. Interactive Effects of Omega-3 Polyunsaturated Fatty Acids and Secondhand Smoke in Mice and Human Subjects. Cardiovasc Toxicol 2021; 21:115-126. [PMID: 32844369 PMCID: PMC7854812 DOI: 10.1007/s12012-020-09601-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 08/14/2020] [Indexed: 10/23/2022]
Abstract
Active smoking and secondhand smoke (SHS) exposure increase the risk of cardiovascular morbidity and mortality. Active smoking is associated with reduced levels of omega-3 polyunsaturated fatty acids (n-3 PUFA) and studies show that n-3 PUFA supplementation can improve smoking-induced vascular dysfunction. However, the relationship between n-3 PUFA and SHS exposure has not been studied. Fat-1 transgenic mice, which convert n-6 to n-3 PUFA, were fed diets with n-3 PUFA or without (n-6 PUFA diet), exposed to air or SHS for 4 weeks, and vasoreactivity, antioxidant indices, and omega-3 index (percent eicosapentaenoic + docosahexaenoic acids in RBC) measured. Compared to air-exposed mice, SHS-enhanced aortic constriction in mice fed the n-6 PUFA diet (omega-3 index, 5.9 ± 0.2%; mean ± SE), but not in mice fed the n-3 PUFA diet (omega-3 index, 7.8 ± 0.6%). SHS also significantly induced mRNA expression of cytochrome P4501A1, NADPH:quinone oxidoreductase, heme oxygenase-1, and angiotensinogen in adipose tissue, and increased antioxidant capacity only in mice on the n-6 PUFA diet. Notably, SHS reduced the omega-3 index by 1.0 percentage point (p = 0.003), compared to air-exposed mice irrespective of diet. Additionally, we recruited human nonsmokers (NS) with and without SHS exposure (n = 40) 19-40 years old and measured the omega-3 index and antioxidant capacity. In human subjects SHS exposure was associated with a significantly lower omega-3 index (NS, 4.4 ± 1.1%; NS + SHS, 3.2 ± 1.0%; mean ± SD, p = 0.002) and higher antioxidant capacity (p < 0.001) than unexposed NS. Thus, SHS exposure is associated with lower levels of n-3 PUFA in mice and humans; however, an omega-3 index of ~ 8% in mice has vasoprotective and antioxidant properties.
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Affiliation(s)
- Emily Wheeler
- Department of Pharmaceutical Sciences, College of Pharmacy, University of New Mexico Health Sciences Center, 2703 Frontier Ave NE MSC09 5630, Albuquerque, NM, 87131, USA
- National Jewish Health, Denver, CO, 80206, USA
| | - Mary Walsh-Wilcox
- Department of Pharmaceutical Sciences, College of Pharmacy, University of New Mexico Health Sciences Center, 2703 Frontier Ave NE MSC09 5630, Albuquerque, NM, 87131, USA
| | - Meera Shah
- Department of Pharmaceutical Sciences, College of Pharmacy, University of New Mexico Health Sciences Center, 2703 Frontier Ave NE MSC09 5630, Albuquerque, NM, 87131, USA
| | - Abinash Achrekar
- Department of Internal Medicine, School of Medicine, University of New Mexico, Albuquerque, NM, 87131, USA
| | - Joe R Anderson
- Department of Pharmacy Practice and Administrative Sciences, College of Pharmacy, University of New Mexico Health Sciences Center, Albuquerque, NM, 87131, USA
| | - Mary K Walker
- Department of Pharmaceutical Sciences, College of Pharmacy, University of New Mexico Health Sciences Center, 2703 Frontier Ave NE MSC09 5630, Albuquerque, NM, 87131, USA.
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9
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Darcey VL, Serafine KM. Omega-3 Fatty Acids and Vulnerability to Addiction: Reviewing Preclinical and Clinical Evidence. Curr Pharm Des 2020; 26:2385-2401. [DOI: 10.2174/1381612826666200429094158] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 04/06/2020] [Indexed: 01/05/2023]
Abstract
Omega-3 (N3) fatty acids are dietary nutrients that are essential for human health. Arguably, one of their most critical contributions to health is their involvement in the structure and function of the nervous system. N3 fatty acids accumulate in neuronal membranes through young adulthood, becoming particularly enriched in a brain region known to be the locus of cognitive control of behavior-the prefrontal cortex (PFC). The PFC undergoes a surge in development during adolescence, coinciding with a life stage when dietary quality and intake of N3 fatty acids tend to be suboptimal. Such low intake may impact neurodevelopment and normative development of cognitive functions suggested to be protective for the risk of subsequent substance and alcohol use disorders (UD). While multiple genetic and environmental factors contribute to risk for and resilience to substance and alcohol use disorders, mounting evidence suggests that dietary patterns early in life may also modulate cognitive and behavioral factors thought to elevate UD risk (e.g., impulsivity and reward sensitivity). This review aims to summarize the literature on dietary N3 fatty acids during childhood and adolescence and risk of executive/ cognitive or behavioral dysfunction, which may contribute to the risk of subsequent UD. We begin with a review of the effects of N3 fatty acids in the brain at the molecular to cellular levels–providing the biochemical mechanisms ostensibly supporting observed beneficial effects. We continue with a review of cognitive, behavioral and neurodevelopmental features thought to predict early substance and alcohol use in humans. This is followed by a review of the preclinical literature, largely demonstrating that dietary manipulation of N3 fatty acids contributes to behavioral changes that impact drug sensitivity. Finally, a review of the available evidence in human literature, suggesting an association between dietary N3 fatty and neurodevelopmental profiles associated with risk of adverse outcomes including UD. We conclude with a brief summary and call to action for additional research to extend the current understanding of the impact of dietary N3 fatty acids and the risk of drug and alcohol UD.
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Affiliation(s)
- Valerie L. Darcey
- Georgetown University, Interdisciplinary Program in Neuroscience, Washington DC, United States
| | - Katherine M. Serafine
- Department of Psychology, The University of Texas at El Paso, El Paso, TX 79968, United States
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10
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Okubo R, Noguchi H, Hamazaki K, Sekiguchi M, Kinoshita T, Katsumata N, Narisawa T, Uezono Y, Xiao J, Matsuoka YJ. Association between blood polyunsaturated fatty acid levels and depressive symptoms in breast cancer survivors. Prostaglandins Leukot Essent Fatty Acids 2018; 139:9-13. [PMID: 30471773 DOI: 10.1016/j.plefa.2018.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 11/01/2018] [Accepted: 11/01/2018] [Indexed: 12/20/2022]
Abstract
In contrast to the cumulative evidence suggesting the inverse association of n-3 polyunsaturated fatty acids (PUFAs) with depression, few studies have examined the association of n-6 PUFAs with depression. In particular, no study has examined the relationship between n-6 PUFAs and depression in cancer patients. Thus, we conducted this cross-sectional study to comprehensively examine the association of n-3 and n-6 PUFAs with depressive symptoms in breast cancer survivors. Adults who had been diagnosed with invasive breast cancer and were not undergoing chemotherapy were enrolled. Blood PUFA composition was determined using capillary blood. Depressive symptoms were assessed using the Hospital Anxiety and Depression Scale (HADS). Among 126 participants, the mean age (standard deviation) was 58 (11) years and 47% had stage I cancer. Multiple regression analysis controlling for possible confounders revealed that the level of total n-6 PUFAs and linoleic acid was significantly associated with the HADS total score (beta = 0.175, p = 0.046 for total n-6 PUFAs; beta = 0.174, p = 0.048 for LA). No significant associations were found for other PUFAs. These findings provide the first evidence suggesting that a higher blood level of total n-6 PUFAs and linoleic acid is significantly associated with higher depressive symptoms among breast cancer survivors. Further studies should examine the positive effects of a reduction in n-6 PUFAs on depressive symptoms in breast cancer survivors using prospective studies, including randomized control trials.
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Affiliation(s)
- Ryo Okubo
- Division of Health Care Research, Center for Public Health Sciences, National Cancer Center Japan, Tokyo, Japan
| | - Hiroko Noguchi
- Division of Health Care Research, Center for Public Health Sciences, National Cancer Center Japan, Tokyo, Japan
| | - Kei Hamazaki
- Department of Public Health, Faculty of Medicine, University of Toyama, Toyama, Japan
| | - Masayuki Sekiguchi
- Department of Degenerative Neurological Diseases, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Takayuki Kinoshita
- Department of Breast Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Noriko Katsumata
- Next Generation Science Institute, Morinaga Milk Industry Co. Ltd., Zama, Kanagawa, Japan
| | - Tomomi Narisawa
- Division of Health Care Research, Center for Public Health Sciences, National Cancer Center Japan, Tokyo, Japan
| | - Yasuhito Uezono
- Division of Cancer Pathophysiology, National Cancer Center Research Institute, Tokyo, Japan
| | - Jinzhong Xiao
- Next Generation Science Institute, Morinaga Milk Industry Co. Ltd., Zama, Kanagawa, Japan
| | - Yutaka J Matsuoka
- Division of Health Care Research, Center for Public Health Sciences, National Cancer Center Japan, Tokyo, Japan.
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11
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Ghosh S, Dyer RA, Beasley CL. Evidence for altered cell membrane lipid composition in postmortem prefrontal white matter in bipolar disorder and schizophrenia. J Psychiatr Res 2017; 95:135-142. [PMID: 28843843 DOI: 10.1016/j.jpsychires.2017.08.009] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 07/24/2017] [Accepted: 08/09/2017] [Indexed: 11/30/2022]
Abstract
Brain imaging suggests that white matter abnormalities, including compromised white matter integrity in the frontal lobe, are shared across bipolar disorder (BD) and schizophrenia (SCZ). However, the precise molecular and cellular correlates remain to be elucidated. Given evidence for widespread alterations in cell membrane lipid composition in both disorders, we sought to investigate whether lipid composition is disturbed in frontal white matter in SCZ and BD. The phospholipids phosphatidylethanolamine (PE) and phosphatidylcholine (PC) were quantified in white matter adjacent to the dorsolateral prefrontal cortex in subjects with BD (n = 34), SCZ (n = 35), and non-psychiatric controls (n = 35) using high-pressure liquid chromatography. Individual fatty acid species and plasmalogens were then quantified separately in PE and PC fractions by gas liquid chromatography. PC was significantly lower in the BD group, compared to controls. The fatty acids PE22:0, PE24:1 and PE20:2n6 were higher, and PC20:4n6, PE22:5n6 and PC22:5n6 lower in the BD group, relative to the control group. PE22:1 was higher and PC20:3n6, PE22:5n6 and PC22:5n6 lower in the SCZ group, compared to the control group. These data provide evidence for altered lipid composition in white matter in both BD and SCZ. Changes in white matter lipid composition could ultimately contribute to dysfunction of frontal white matter circuits in SCZ and BD.
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Affiliation(s)
- Sanjoy Ghosh
- Department of Biology, Irving K. Barber School of Arts & Sciences, University of British Columbia-Okanagan, Kelowna, British Columbia, Canada
| | - Roger A Dyer
- Nutrition and Metabolism Research Program, BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Clare L Beasley
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada.
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12
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Rifkin SB, Shrubsole MJ, Cai Q, Smalley WE, Ness RM, Swift LL, Zheng W, Murff HJ. PUFA levels in erythrocyte membrane phospholipids are differentially associated with colorectal adenoma risk. Br J Nutr 2017; 117:1615-1622. [PMID: 28660850 PMCID: PMC5891121 DOI: 10.1017/s0007114517001490] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Dietary intake of PUFA has been associated with colorectal neoplasm risk; however, results from observational studies have been inconsistent. Most prior studies have utilised self-reported dietary measures to assess fatty acid exposure which might be more susceptible to measurement error and biases compared with biomarkers. The purpose of this study was to determine whether erythrocyte phospholipid membrane PUFA percentages are associated with colorectal adenoma risk. We included data from 904 adenoma cases and 835 polyp-free controls who participated in the Tennessee Colorectal Polyp Study, a large colonoscopy-based case-control study. Erythrocyte membrane PUFA percentages were measured using GC. Conditional logistic regression was used to calculate adjusted OR for risk of colorectal adenomas with erythrocyte membrane PUFA. Higher erythrocyte membrane percentages of arachidonic acid was associated with an increased risk of colorectal adenomas (adjusted OR 1·66; 95 % CI 1·05, 2·62, P trend=0·02) comparing the highest tertile to the lowest tertile. The effect size for arachidonic acid was more pronounced when restricting the analysis to advanced adenomas only. Higher erythrocyte membrane EPA percentages were associated with a trend towards a reduced risk of advanced colorectal adenomas (P trend=0·05). Erythrocyte membrane arachidonic acid percentages are associated with an increased risk of colorectal adenomas.
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Affiliation(s)
- Samara B Rifkin
- 1Division of Gastroenterology and Hepatology,Johns Hopkins University School of Medicine,1800 Orleans Street,Baltimore, MD 21287,USA
| | - Martha J Shrubsole
- 2Division of Epidemiology,Vanderbilt University Medical Center,2525 West End Avenue,Suite 800,Nashville, TN 37203,USA
| | - Qiuyin Cai
- 2Division of Epidemiology,Vanderbilt University Medical Center,2525 West End Avenue,Suite 800,Nashville, TN 37203,USA
| | - Walter E Smalley
- 4Department of Health Policy,Vanderbilt University Medical Center,2525 West End Avenue,Suite 1200, Nashville, TN 37203,USA
| | - Reid M Ness
- 5Division of Gastroenterology,Vanderbilt University Medical Center,1211 Medical Center Drive,Nashville, TN 37232,USA
| | - Larry L Swift
- 6Department of Pathology, Microbiology and Immunology,Vanderbilt University Medical Center,1211 Medical Center Drive,Nashville, TN 37232,USA
| | - Wei Zheng
- 2Division of Epidemiology,Vanderbilt University Medical Center,2525 West End Avenue,Suite 800,Nashville, TN 37203,USA
| | - Harvey J Murff
- 3Geriatric Research Education and Clinical Center (GRECC),Department of Veterans Affairs,Tennessee Valley Healthcare System,1310 24th Avenue S,Nashville, TN 37212,USA
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13
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Gomes Neto AW, Sotomayor CG, Pranger IG, van den Berg E, Gans ROB, Soedamah-Muthu SS, Navis GJ, Bakker SJL. Intake of Marine-Derived Omega-3 Polyunsaturated Fatty Acids and Mortality in Renal Transplant Recipients. Nutrients 2017; 9:nu9040363. [PMID: 28379169 PMCID: PMC5409702 DOI: 10.3390/nu9040363] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 03/27/2017] [Accepted: 03/30/2017] [Indexed: 12/13/2022] Open
Abstract
The effect of marine-derived omega-3 polyunsaturated fatty acids (n-3 PUFA) on long-term outcome in renal transplant recipients (RTR) remains unclear. We investigated whether marine-derived n-3 PUFA intake is associated with all-cause and cardiovascular (CV) mortality in RTR. Intake of eicosapentaenoic acid plus docosahexaenoic acid (EPA-DHA) was assessed using a validated Food Frequency Questionnaire. Cox regression analyses were performed to evaluate the associations of EPA-DHA intake with all-cause and CV mortality. We included 627 RTR (age 53 ± 13 years). EPA-DHA intake was 102 (42–215) mg/day. During median follow-up of 5.4 years, 130 (21%) RTR died, with 52 (8.3%) due to CV causes. EPA-DHA intake was associated with lower risk of all-cause mortality (Hazard Ratio (HR) 0.85; 95% confidence interval (95% CI) 0.75–0.97). Age (p= 0.03) and smoking status (p = 0.01) significantly modified this association, with lower risk of all-cause and CV mortality particularly in older (HR 0.75, 95% CI 0.61–0.92; HR 0.68, 95% CI 0.48–0.95) and non-smoking RTR (HR 0.80, 95% CI 0.68–0.93; HR 0.74, 95% CI 0.56–0.98). In conclusion, marine-derived n-3 PUFA intake is inversely associated with risk of all-cause and CV mortality in RTR. The strongest associations were present in subgroups of patients, which adds further evidence to the plea for EPA-DHA supplementation, particularly in elderly and non-smoking RTR.
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Affiliation(s)
- António W Gomes Neto
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Hanzeplein 1, Groningen 9700 RB, The Netherlands.
| | - Camilo G Sotomayor
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Hanzeplein 1, Groningen 9700 RB, The Netherlands.
| | - Ilse G Pranger
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Hanzeplein 1, Groningen 9700 RB, The Netherlands.
| | - Else van den Berg
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Hanzeplein 1, Groningen 9700 RB, The Netherlands.
| | - Rijk O B Gans
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Hanzeplein 1, Groningen 9700 RB, The Netherlands.
| | - Sabita S Soedamah-Muthu
- Division of Human Nutrition, Wageningen University & Research, Droevendaalsesteeg 4, Wageningen 6708 PB, The Netherlands.
| | - Gerjan J Navis
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Hanzeplein 1, Groningen 9700 RB, The Netherlands.
| | - Stephan J L Bakker
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Hanzeplein 1, Groningen 9700 RB, The Netherlands.
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