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Esteves Rossini E, Lourival Zanoveli Cunha J, L B Costa G, Araujo Melo K, Cassemiro Micheleto JP, Miranda Pereira Fausto V, Quintiliano Pedroza L, Sotero Fragoso T, Leão de Melo Neto V, Cavalcante Oliveira MJ. Childhood adverse experiences and clinical manifestations in women with systemic lupus erythematosus. Lupus 2024; 33:511-519. [PMID: 38457921 DOI: 10.1177/09612033241238056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2024]
Abstract
BACKGROUND Patients with a history of adverse childhood experiences (ACEs) have a higher incidence of developing autoimmune diseases such as systemic lupus erythematosus. OBJECTIVE The objective is to associate the ACE with the clinical manifestations of SLE in adult women. METHODS This is a cross-sectional observational analytical study in a sample of women diagnosed with SLE, whose data were collected through interviews and a review of medical records. The ACE were identified using the Childhood Trauma Questionnaire (CTQ) and were associated with sociodemographic and clinical data, as well as the presence of harm. RESULTS The sample was composed of 97 women. In this study, significant associations were found between physical abuse and oral ulcers (p = .006) and nephritis (p = .032); between sexual abuse and Sjogren's syndrome (p = .024) and oral ulcers (p = .035); between physical neglect and photosensitivity (p = .024) and oral ulcers (p = .039); and between emotional neglect and diabetes mellitus (p = .033). CONCLUSION Individuals with a positive history of ACE have significant associations with certain clinical manifestations of SLE and subtypes of ACE, underscoring the importance of preventing childhood trauma to improve adult health. Further studies are needed to elucidate the impact of ACE on adult health.
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Affiliation(s)
| | | | | | | | | | | | | | - Thiago Sotero Fragoso
- Department of Rheumatology, University Hospital Prof. Alberto Antunes, Maceio, Brazil
| | | | - Michelle Jacintha Cavalcante Oliveira
- Faculty of Medicine, Federal University of Alagoas, Maceio, Brazil
- Department of Medical Sciences, Federal University of Ceará, Fortaleza, Brazil; Department of Medical Sciences, Federal University of Alagoas, Maceio, Brazil
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2
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Ramessar N, Borad A, Schlesinger N. The effect of Omega-3 fatty acid supplementation in systemic lupus erythematosus patients: A systematic review. Lupus 2022; 31:287-296. [PMID: 35023407 DOI: 10.1177/09612033211067985] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Many rheumatologists are inundated with questions about what "natural remedies" and "anti-autoimmune diets" exist for decreasing Systemic Lupus Erythematosus (SLE) disease activity. Over the last three decades, there has been an abundance of data from several different trials about omega-3 fatty acids sourced from fish oil, but the findings have been contradictory. This review seeks to present this data so that evidence-based recommendations can be given to patients, supporting the use of an adjuvant regimen with their present immunosuppression. METHODS A literature search was conducted using the PubMed, Google Scholar, MEDLINE, and Scopus electronic databases to retrieve relevant articles for this review. Trials conducted on human subjects with SLE with full publications in English were included from 1 January 1980 to 1 April 2021. The impact of fish oil-derived omega-3 fatty acid supplementation on specific clinical features, the innate and adaptive immune response, biomarkers, and disease activity measures were assessed. The initial search yielded 7519 articles, but only 13 met our criteria and were eligible for this review. RESULTS Data from thirteen articles were assessed. Ten trials assessed disease activity as an outcome, with eight trials demonstrating an improvement in patients in the omega-3 fatty acid group as assessed by a validated clinical tool or individual patient criteria. There was a significant improvement in Systemic Lupus Activity Measure-Revised (SLAM-R) scores at week 12 (p = .009) and week 24 (p < .001). Additionally, a reduction of urinary 8-isoprostane, a non-invasive marker of disease activity, was observed. There was no treatment benefit seen with respect to renal parameters such as serum creatinine or 24-hour urine protein; or systemic parameters such as C3, C4, or anti-double stranded DNA (anti-dsDNA) levels regardless of the dose of the omega-3 LUPUS fatty acids or duration of the trial. CONCLUSION While there is conflicting evidence about the benefits of omega-3 fatty acid supplementation on SLE disease activity, specific measures have demonstrated benefits. Current data show that there is a potential benefit on disease activity as demonstrated by SLAM-R, Systemic Lupus Erythematosus Disease Activity Index (SLEDAI), and British Isles Lupus Assessment Group (BILAG) scores and plasma membrane arachidonic acid composition and urinary 8-isoprostane levels, with minimal adverse events.
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Affiliation(s)
- Nina Ramessar
- Rheumatology, Rutgers Robert Wood Johnson Medical School (RWJMS)RINGGOLD, New Brunswick, NJ, USA
| | - Abhilasha Borad
- Medicine, 43982Rutgers Robert Wood Johnson Medical School (RWJMS), New Brunswick, NJ, USA
| | - Naomi Schlesinger
- Rheumatology, Rutgers Robert Wood Johnson Medical School (RWJMS)RINGGOLD, New Brunswick, NJ, USA
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3
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Hansen MW, Ørn S, Erevik CB, Bjørkavoll-Bergseth MF, Skadberg Ø, Melberg TH, Aakre KM, Kleiven Ø. Regular consumption of cod liver oil is associated with reduced basal and exercise-induced C-reactive protein levels; a prospective observational trial : A NEEDED (The North Sea Race Endurance Exercise Study) 2014 sub-study. J Int Soc Sports Nutr 2021; 18:51. [PMID: 34183020 PMCID: PMC8240263 DOI: 10.1186/s12970-021-00437-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 04/29/2021] [Indexed: 12/31/2022] Open
Abstract
Background Dietary supplement use among recreational athletes is common, with the intention of reducing inflammation and improving recovery. We aimed to describe the relationship between omega-3 fatty acid supplement use and inflammation induced by strenuous exercise. Methods C-reactive protein (CRP) concentrations were measured in 1002 healthy recreational athletes before and 24 h after a 91-km bicycle race. The use of omega-3 fatty acid supplements was reported in 856 out of 1002 recreational athletes, and the association between supplement use and the exercise-induced CRP response was assessed. Results Two hundred seventy-four subjects reported regular use of omega-3 fatty acid supplements. One hundred seventy-three of these used cod liver oil (CLO). Regular users of omega-3 fatty acid supplements had significantly lower basal and exercise-induced CRP levels as compared to non-users (n = 348, p < 0.001). Compared to non-users, regular users had a 27% (95% confidence interval (CI): 14–40) reduction in Ln CRP response (unadjusted model, p < 0.001) and 16% (95% CI: 5–28, p = 0.006) reduction after adjusting for age, sex, race duration, body mass index, delta creatine kinase, MET hours per week, resting heart rate and higher education. CLO was the primary driver of this response with a 34% (95% CI: 19–49) reduction (unadjusted model, p < 0.001) compared to non-users. Corresponding numbers in the adjusted model were 24% (95% CI: 11–38, p < 0.001). Conclusion Basal CRP levels were reduced, and the exercise-induced CRP response was attenuated in healthy recreational cyclists who used omega-3 fatty acid supplements regularly. This effect was only present in regular users of CLO. Trial registration NCT02166216, registered June 18, 2014 – Retrospectively registered. Supplementary Information The online version contains supplementary material available at 10.1186/s12970-021-00437-1.
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Affiliation(s)
- Mette Wærstad Hansen
- Cardiology Department, Stavanger University Hospital, PO 8400, 4068, Stavanger, Norway
| | - Stein Ørn
- Cardiology Department, Stavanger University Hospital, PO 8400, 4068, Stavanger, Norway.,Department of Electrical Engineering and Computer Science, University of Stavanger, Stavanger, Norway
| | - Christine B Erevik
- Cardiology Department, Stavanger University Hospital, PO 8400, 4068, Stavanger, Norway
| | | | - Øyvind Skadberg
- Department of Biochemistry, Stavanger University Hospital, Stavanger, Norway
| | - Tor H Melberg
- Cardiology Department, Stavanger University Hospital, PO 8400, 4068, Stavanger, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Kristin M Aakre
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway.,Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Øyunn Kleiven
- Cardiology Department, Stavanger University Hospital, PO 8400, 4068, Stavanger, Norway.
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4
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Gorczyca D, Szponar B, Paściak M, Czajkowska A, Szmyrka M. Serum levels of n-3 and n-6 polyunsaturated fatty acids in patients with systemic lupus erythematosus and their association with disease activity: a pilot study. Scand J Rheumatol 2021; 51:230-236. [PMID: 34169789 DOI: 10.1080/03009742.2021.1923183] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Objective: Polyunsaturated fatty acids (PUFAs) may modulate the inflammatory process in systemic autoimmune diseases, including systemic lupus erythematosus (SLE). The aim of this study was to assess the serum concentrations of essential 18-carbon PUFAs and their long-chain derivatives in patients with SLE and healthy controls, and to analyse their associations with laboratory and clinical features of the disease.Method: n-6 and n-3 PUFA composition was assessed in the sera of 30 SLE patients and 20 healthy controls using gas chromatography-mass spectrometry. We investigated the associations between PUFAs and disease activity measured with Systemic Lupus Erythematosus Activity Index (SLEDAI) scores, erythrocyte sedimentation rate, C-reactive protein, complement C3 and C4 concentrations, anti-nuclear antibody (ANA) titre, anti-double-stranded DNA (anti-dsDNA) antibody concentration, and medications.Results: Serum linoleic acid (LA) and α-linolenic acid concentrations were significantly higher in SLE patients compared with healthy controls. LA concentration correlated positively with the ANA titre and corticosteroid doses; eicosapentaenoic acid (EPA) and docosahexaenoic acid correlated inversely with anti-dsDNA antibody concentration. Patients treated with immunosuppressants had significantly lower concentrations of LA, arachidonic acid, and EPA.Conclusion: Both n-6 and n-3 PUFA precursors can participate in the inflammatory process in SLE patients. The mechanism of the PUFA metabolism disturbance needs further exploration.
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Affiliation(s)
- D Gorczyca
- Third Department and Clinic of Pediatrics, Immunology and Rheumatology of Developmental Age, Wroclaw Medical University, Wroclaw, Poland
| | - B Szponar
- Laboratory of Medical Microbiology, Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, Wroclaw, Poland
| | - M Paściak
- Laboratory of Medical Microbiology, Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, Wroclaw, Poland
| | - A Czajkowska
- Laboratory of Medical Microbiology, Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, Wroclaw, Poland
| | - M Szmyrka
- Department of Rheumatology and Internal Diseases, Wroclaw Medical University, Wroclaw, Poland
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Sepidarkish M, Rezamand G, Qorbani M, Heydari H, Estêvão MD, Omran D, Morvaridzadeh M, Roffey DM, Farsi F, Ebrahimi S, Shokri F, Heshmati J. Effect of omega-3 fatty acids supplementation on adipokines: a systematic review and meta-analysis of randomized controlled trials. Crit Rev Food Sci Nutr 2021; 62:7561-7575. [PMID: 33998914 DOI: 10.1080/10408398.2021.1915743] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Although a large body of literature reported the beneficial effects of omega-3 fatty acids (omega-3 FAs) consumption on adipokines levels, but recent findings from clinical trials are not univocal. The aim of this systematic review and meta-analysis was to evaluate the effect of omega-3 FAs supplements on adipokines. METHODS We searched Medline, Web of Science, Scopus, Embase, and Cochrane Library from inception to August 2020 without any particular language limitations. Outcomes were summarized as standardized mean difference (SMD) with 95% confidence intervals (CIs) estimated from Hedge's g and random effects modeling. RESULTS Fifty-two trials involving 4,568 participants were included. Omega-3 FAs intake was associated with a significant increase in plasma adiponectin levels (n = 43; 3,434 participants; SMD: 0.21, 95% CI: 0.04, 0.37; p = 0.01; I2= 80.14%). This meta-analysis indicates that supplementing participants with omega-3 fatty acids more than 2000 mg daily and more than 10 weeks resulted in a significant and more favorable improvement in plasma adiponectin levels. However, omega-3 FAs intake had no significant effect on leptin levels (SMD: -0.02, 95% CI: -0.20, 0.17, I2= 54.13%). CONCLUSION The evidence supports a beneficial effect of omega-3 FAs intake on serum adiponectin levels but does not appear to impact on leptin concentrations. Larger well-designed RCTs are still required to evaluate the effect of omega-3 FAs on leptin in specific diseases.
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Affiliation(s)
- Mahdi Sepidarkish
- Department of Biostatistics and Epidemiology, School of Public Health, Babol University of Medical Sciences, Babol, Iran
| | - Gholamreza Rezamand
- Colorectal Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mostafa Qorbani
- Non-communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran.,Chronic Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Hafez Heydari
- Cellular and Molecular Research Center, Sabzevar University of Medical Sciences, Sabzevar, Iran
| | - M Dulce Estêvão
- Universidade do Algarve, Escola Superior de Saúde, Campus de Gambelas, Faro, Portugal
| | - Dalia Omran
- Department of Endemic Medicine and Hepatology, Thabet hospital for Endemic diseases, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mojgan Morvaridzadeh
- Department of Nutritional Science, School of Nutritional Science and Food Technology, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Darren M Roffey
- Vancouver General Hospital, Vancouver Coastal Health, Vancouver, Canada
| | - Farnaz Farsi
- Student Research Committee, Department of Nutrition, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Sara Ebrahimi
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, Australia
| | - Fatemeh Shokri
- Department of Health Education and Promotion, Iran University of Medical Sciences, Tehran, Iran
| | - Javad Heshmati
- Department of Nutritional Science, School of Nutritional Science and Food Technology, Kermanshah University of Medical Sciences, Kermanshah, Iran
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6
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Vordenbäumen S, Sokolowski A, Kutzner L, Rund KM, Düsing C, Chehab G, Richter JG, Brinks R, Schneider M, Schebb NH. Erythrocyte membrane polyunsaturated fatty acid profiles are associated with systemic inflammation and fish consumption in systemic lupus erythematosus: a cross-sectional study. Lupus 2020; 29:554-559. [PMID: 32188303 DOI: 10.1177/0961203320912326] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Objective This study aimed to assess polyunsaturated fatty acid (PUFA) status and association with systemic inflammation and fish consumption in systemic lupus erythematosus (SLE). Methods Parameters of PUFA status including the proportion of omega-6 and -3 fatty acids in highly unsaturated fatty acids (omega-6%, omega-3%), essential fatty acids linoleic acid (LA) and alpha-linolenic acid (ALA), the omega-6 PUFA arachidonic acid (ARA) and the sum of key omega-3 PUFA eicosapentaenoic acid+docosahexaenoic acid (omega-3 status) were measured by gas chromatography in 68 SLE patients (88.2% female, aged 45.7±12.5 years). Associations with serum CRP, disease activity, damage and fish consumption were assessed by linear regression modelling adjusted for age, sex and body mass index. Associations are reported in terms of regression coefficients (β). Results Omega-6 PUFA were associated with higher CRP: omega-6% (β = 0.052, p = 0.02), the ratio of LA/ALA (β = 0.007, p = 0.02) and ARA (β = 0.308, p = 0.001). Conversely, omega-3% was associated with lower CRP (β = −0.051, p = 0.02). Increased dietary PUFA consumption from fish (g/day) was linked to a higher omega-3 status (β = 2.21, p = 0.02) and lower self-reported damage (Brief Index of Lupus Damage; β = −3.22, p = 0.02). Conclusions Omega-3 and omega-6 fatty acid status differentially reflect systemic inflammation in SLE and are linked to fish consumption.
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Affiliation(s)
- Stefan Vordenbäumen
- Heinrich-Heine-University Düsseldorf, Medical Faculty, Rheumatology and Hiller Research Unit, Düsseldorf, Germany
| | - Alexander Sokolowski
- Heinrich-Heine-University Düsseldorf, Medical Faculty, Rheumatology and Hiller Research Unit, Düsseldorf, Germany
| | - Laura Kutzner
- University of Wuppertal, Faculty of Mathematics and Natural Sciences, Wuppertal, Germany
| | - Katharina M Rund
- University of Wuppertal, Faculty of Mathematics and Natural Sciences, Wuppertal, Germany
| | - Christina Düsing
- Heinrich-Heine-University Düsseldorf, Medical Faculty, Rheumatology and Hiller Research Unit, Düsseldorf, Germany
| | - Gamal Chehab
- Heinrich-Heine-University Düsseldorf, Medical Faculty, Rheumatology and Hiller Research Unit, Düsseldorf, Germany
| | - Jutta G Richter
- Heinrich-Heine-University Düsseldorf, Medical Faculty, Rheumatology and Hiller Research Unit, Düsseldorf, Germany
| | - Ralph Brinks
- Heinrich-Heine-University Düsseldorf, Medical Faculty, Rheumatology and Hiller Research Unit, Düsseldorf, Germany
| | - Matthias Schneider
- Heinrich-Heine-University Düsseldorf, Medical Faculty, Rheumatology and Hiller Research Unit, Düsseldorf, Germany
| | - Nils H Schebb
- University of Wuppertal, Faculty of Mathematics and Natural Sciences, Wuppertal, Germany
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7
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Raygan F, Taghizadeh M, Mirhosseini N, Akbari E, Bahmani F, Memarzadeh MR, Sharifi N, Jafarnejad S, Banikazemi Z, Asemi Z. A comparison between the effects of flaxseed oil and fish oil supplementation on cardiovascular health in type 2 diabetic patients with coronary heart disease: A randomized, double-blinded, placebo-controlled trial. Phytother Res 2019; 33:1943-1951. [PMID: 31190359 DOI: 10.1002/ptr.6393] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 04/13/2019] [Accepted: 04/28/2019] [Indexed: 01/15/2023]
Abstract
This study compared the effects of flaxseed and fish oil supplementation on cardiovascular risk parameters in diabetic patients with coronary heart disease. Participants were randomly allocated into three intervention groups to receive either 1,000 mg of omega-3 fatty acids from fish oil or 1,000 mg of omega-3 fatty acids from flaxseed oil or placebo (n = 30 each group) twice a day for 12 weeks. A significant reduction in insulin levels (.04) was observed following flaxseed oil and fish oil supplementation compared with the placebo. In addition, a significant reduction in high-sensitivity C-reactive protein (.02) was seen after flaxseed oil supplementation compared with the placebo and a significant increase in total nitrite (.001) was seen after flaxseed oil and fish oil intake compared with placebo. Additionally, a significant increase in total antioxidant capacity (p < .001) after consuming flaxseed oil and fish oil compared with placebo and glutathione levels (.001) after consuming fish oil compared with flaxseed oil and placebo was observed. Overall, our study revealed the beneficial effects of flaxseed oil and fish oil supplementation on few metabolic profiles. This study suggests that the effect of flaxseed oil in reducing insulin and increasing total nitrite and total antioxidant capacity is similar to fish oil.
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Affiliation(s)
- Fariba Raygan
- Department of Cardiology, School of Medicine, Kashan University of Medical Sciences, Kashan, Iran
| | - Mohsen Taghizadeh
- Research Center for Biochemistry and Nutrition in Metabolic Diseases, Kashan University of Medical Sciences, Kashan, Iran
| | - Naghmeh Mirhosseini
- School of Public Health, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Elmira Akbari
- Physiology Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | - Fereshteh Bahmani
- Research Center for Biochemistry and Nutrition in Metabolic Diseases, Kashan University of Medical Sciences, Kashan, Iran
| | - Mohammad Reza Memarzadeh
- Research Center for Biochemistry and Nutrition in Metabolic Diseases, Kashan University of Medical Sciences, Kashan, Iran
| | - Nasrin Sharifi
- Research Center for Biochemistry and Nutrition in Metabolic Diseases, Kashan University of Medical Sciences, Kashan, Iran
| | - Sadegh Jafarnejad
- Research Center for Biochemistry and Nutrition in Metabolic Diseases, Kashan University of Medical Sciences, Kashan, Iran
| | - Zarrin Banikazemi
- Research Center for Biochemistry and Nutrition in Metabolic Diseases, Kashan University of Medical Sciences, Kashan, Iran
| | - Zatollah Asemi
- Research Center for Biochemistry and Nutrition in Metabolic Diseases, Kashan University of Medical Sciences, Kashan, Iran
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de Medeiros MCS, Medeiros JCA, de Medeiros HJ, Leitão JCGDC, Knackfuss MI. Dietary intervention and health in patients with systemic lupus erythematosus: A systematic review of the evidence. Crit Rev Food Sci Nutr 2018; 59:2666-2673. [PMID: 29648479 DOI: 10.1080/10408398.2018.1463966] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Objective: The aim of this study was to evaluate the scientific evidence of dietary intervention, either through diet or supplementation, and its effects on the health of patients with systemic lupus erythematosus. Methods: Literature searches were conducted using Scopus, PubMed, BioMed Central and Science Direct databases. The terms used for the search were diet, nutritional support, nutrition therapy and systemic lupus erythematosus. Results: Eleven studies with interventions related to supplementation of omega-3 fatty acids, vitamin D and turmeric, as well as changes in diet composition, such as low glycaemic index diet were identified. Conclusions: The studies evidenced that omega-3 supplementation reduced inflammation, disease activity, endothelial dysfunction and oxidative stress; vitamin D supplementation increased serum levels, reduced inflammatory and hemostatic markers; turmeric supplementation reduced proteinuria, hematuria and systolic blood pressure; and low glycaemic index diet caused weight loss and reduced fatigue.
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Affiliation(s)
| | | | | | - José Carlos Gomes de Carvalho Leitão
- Universidade de Trás-os-Montes e Alto Douro , Vila Real , Portugal.,CIDESD-Research Center in Sports Sciences, Health Sciences and Human Development
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