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Caba-Flores MD, Cardenas-Tueme M, Viveros-Contreras R, Martínez-Valenzuela C, Zurutuza-Lorméndez JI, Ortiz-López R, Cruz-Carrillo G, Neme Kuri JG, Huerta Morales D, Ponce Ramos S, Nava Bustos E, Camacho-Morales A. Preterm Delivery in Obese Mothers Predicts Tumor Necrosis Factor-α Levels in Breast Milk. Breastfeed Med 2023; 18:934-942. [PMID: 38100442 DOI: 10.1089/bfm.2023.0153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Abstract
Background: Breast milk (BM) is a nutritive fluid that is rich in bioactive components such as hormones and cytokines that can shape the newborn's feeding habits and program the newborn's immature immune system. BM components can change under different scenarios that include maternal body mass index (BMI) and premature birth. This study aimed to study the interaction of premature status or maternal obesity on the hormonal and cytokine profile in BM according to the sex of the offspring. Materials and Methods: We recruited 31 women with preterm births from the Centro de Alta Especialidad Dr. Rafael Lucio in Mexico. Luminex multiplexing assay was used for quantifying cytokine profile of monocyte chemoattractant protein-1, tumor necrosis factor (TNF)-α, interferon-γ, interleukin (IL)1-β, IL-2, IL-4, IL-6, IL-7, and hormones insulin, ghrelin, leptin, and glucagon in mature BM samples. Biological modeling was performed to predict the interaction between cytokines and hormones, maternal BMI status, infant birth sex, parity, and gestational age. Results: BM multiplex analysis showed positive correlations for TNF-α and increasing prematurity and for higher maternal BMI and IL-2, IL-4, and IL-6 cytokines. Multiple regression models identified an interaction between maternal BMI and gestational weeks in male infants that is associated to TNF-α accumulation in BM. Biological modeling predicts that preterm delivery in mothers with obesity modulates TNF- α levels in mature BM of women with male offspring. Conclusion: Prematurity and obesity modify BM's immune profile. TNF- α expression increases as prematurity increases, and maternal BMI correlates positively with increases in IL-2, IL-6, and IL-4. Our multiple regression model also shows that maternal BMI and gestational weeks in male infants predict TNF-α.
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Affiliation(s)
- Mario Daniel Caba-Flores
- Departamento de Bioquímica y Medicina Molecular, Facultad de Medicina, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
- Unidad de Neurometabolismo, Centro de Investigación y Desarrollo en Ciencias de la Salud, Universidad Autónoma de Nuevo León, San Nicolás de los Garza, Nuevo León, México
| | - Marcela Cardenas-Tueme
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud and The Institute for Obesity Research, Monterrey, Nuevo León, México
- Centro de Investigación en Nutrición y Salud Pública, Facultad de Salud Pública y Nutrición, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | | | - Carmen Martínez-Valenzuela
- Unidad de Investigación en Ambiente y Salud, Universidad Autónoma de Occidente, Los Mochis, Sinaloa, México
| | - Jorge Iván Zurutuza-Lorméndez
- Centro de Investigaciones Biomédicas, Universidad Veracruzana, Xalapa, Veracruz, México
- Doctorado en Ciencias Biomédicas, Centro de Investigaciones Biomédicas, Universidad Veracruzana, Xalapa, Veracruz, México
| | - Roció Ortiz-López
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud and The Institute for Obesity Research, Monterrey, Nuevo León, México
| | - Gabriela Cruz-Carrillo
- Departamento de Bioquímica y Medicina Molecular, Facultad de Medicina, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
- Unidad de Neurometabolismo, Centro de Investigación y Desarrollo en Ciencias de la Salud, Universidad Autónoma de Nuevo León, San Nicolás de los Garza, Nuevo León, México
| | - Juan Gerardo Neme Kuri
- Subdirección de enseñanza, Centro de Alta Especialidad Dr. Rafael Lucio, Xalapa, Veracruz, México
| | - David Huerta Morales
- Departamento de Pediatría, Centro de Alta Especialidad Dr. Rafael Lucio, Xalapa, Veracruz, México
| | - Samantha Ponce Ramos
- Departamento de Pediatría, Centro de Alta Especialidad Dr. Rafael Lucio, Xalapa, Veracruz, México
| | - Edith Nava Bustos
- Coordinación Hospital Amigo del Niño y de la Niña, Centro de Alta Especialidad Dr. Rafael Lucio, Xalapa, Veracruz, México
| | - Alberto Camacho-Morales
- Departamento de Bioquímica y Medicina Molecular, Facultad de Medicina, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
- Unidad de Neurometabolismo, Centro de Investigación y Desarrollo en Ciencias de la Salud, Universidad Autónoma de Nuevo León, San Nicolás de los Garza, Nuevo León, México
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A Higher Healthy Eating Index Is Associated with Decreased Markers of Inflammation and Lower Odds for Being Overweight/Obese Based on a Case-Control Study. Nutrients 2022; 14:nu14235127. [PMID: 36501156 PMCID: PMC9738448 DOI: 10.3390/nu14235127] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 11/22/2022] [Accepted: 11/27/2022] [Indexed: 12/03/2022] Open
Abstract
Obesity is a health risk characterized by chronic inflammation, and food choices are strongly associated with its etiology. Our objective was to investigate the association between dietary patterns and the healthy eating index (HEI) with the odds of overweight/obesity and related inflammatory markers. Within a population-based case-control study, we collected data and samples from 793 normal-weight and 812 overweight/obese Iranian people (based on either body mass index (BMI) or body surface area (BSA)). Dietary intake and HEI scores were obtained via a validated 124-item food frequency questionnaire. Anthropometric and socioeconomic parameters, as well as blood inflammatory markers, were measured. Participants with higher HEI scores had higher serum high-density lipoprotein-cholesterol (HDL-C) and significantly lower energy intake. Water consumption in the overweight/obese group was significantly lower than in the control group. In the final models using partial correlation and controlling for multiple confounders, there was a significant inverse correlation between HEI and interleukin-4 (IL-4, R = -0.063), IL-1β (R = -0.054), and high-sensitivity C-reactive protein (hs-CRP, R = -0.069). Based on multivariable logistic regression models adjusted for multiple confounders, there was a significant association between HEI as a continuous variable (OR = 0.993, 95% CI: 0.988-0.999) and categorical variable (OR = 0.801, 95% CI: 0.658-0.977) and odds of overweight/obesity across BMI groups. The dietary patterns in the case and control groups however were similar, and we failed to find a significant association between HEI and odds of overweight/obesity based on BSA. Adherence to healthy eating recommendations may be a prudent recommendation to prevent overweight/obesity and keeping inflammatory indicators low.
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Kahn D, Macias E, Zarini S, Garfield A, Zemski Berry K, MacLean P, Gerszten RE, Libby A, Solt C, Schoen J, Bergman BC. Exploring Visceral and Subcutaneous Adipose Tissue Secretomes in Human Obesity: Implications for Metabolic Disease. Endocrinology 2022; 163:6678177. [PMID: 36036084 PMCID: PMC9761573 DOI: 10.1210/endocr/bqac140] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Indexed: 11/19/2022]
Abstract
Adipose tissue secretions are depot-specific and vary based on anatomical location. Considerable attention has been focused on visceral (VAT) and subcutaneous (SAT) adipose tissue with regard to metabolic disease, yet our knowledge of the secretome from these depots is incomplete. We conducted a comprehensive analysis of VAT and SAT secretomes in the context of metabolic function. Conditioned media generated using SAT and VAT explants from individuals with obesity were analyzed using proteomics, mass spectrometry, and multiplex assays. Conditioned media were administered in vitro to rat hepatocytes and myotubes to assess the functional impact of adipose tissue signaling on insulin responsiveness. VAT secreted more cytokines (IL-12p70, IL-13, TNF-α, IL-6, and IL-8), adipokines (matrix metalloproteinase-1, PAI-1), and prostanoids (TBX2, PGE2) compared with SAT. Secretome proteomics revealed differences in immune/inflammatory response and extracellular matrix components. In vitro, VAT-conditioned media decreased hepatocyte and myotube insulin sensitivity, hepatocyte glucose handling, and increased basal activation of inflammatory signaling in myotubes compared with SAT. Depot-specific differences in adipose tissue secretome composition alter paracrine and endocrine signaling. The unique secretome of VAT has distinct and negative impact on hepatocyte and muscle insulin action.
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Affiliation(s)
- Darcy Kahn
- Division of Endocrinology, Metabolism and Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Emily Macias
- Division of Endocrinology, Metabolism and Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Simona Zarini
- Division of Endocrinology, Metabolism and Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Amanda Garfield
- Division of Endocrinology, Metabolism and Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Karin Zemski Berry
- Division of Endocrinology, Metabolism and Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Paul MacLean
- Division of Endocrinology, Metabolism and Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Robert E Gerszten
- The Cardiovascular Research Center and Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Andrew Libby
- Division of Endocrinology, Metabolism and Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Claudia Solt
- Division of Endocrinology, Metabolism and Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Jonathan Schoen
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Bryan C Bergman
- Correspondence: Bryan Bergman, PhD, Division of Endocrinology, Diabetes, and Metabolism, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA.
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Alam A, Abubaker Bagabir H, Sultan A, Siddiqui MF, Imam N, Alkhanani MF, Alsulimani A, Haque S, Ishrat R. An Integrative Network Approach to Identify Common Genes for the Therapeutics in Tuberculosis and Its Overlapping Non-Communicable Diseases. Front Pharmacol 2022; 12:770762. [PMID: 35153741 PMCID: PMC8829040 DOI: 10.3389/fphar.2021.770762] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 12/27/2021] [Indexed: 12/15/2022] Open
Abstract
Tuberculosis (TB) is the leading cause of death from a single infectious agent. The estimated total global TB deaths in 2019 were 1.4 million. The decline in TB incidence rate is very slow, while the burden of noncommunicable diseases (NCDs) is exponentially increasing in low- and middle-income countries, where the prevention and treatment of TB disease remains a great burden, and there is enough empirical evidence (scientific evidence) to justify a greater research emphasis on the syndemic interaction between TB and NCDs. The current study was proposed to build a disease-gene network based on overlapping TB with NCDs (overlapping means genes involved in TB and other/s NCDs), such as Parkinson’s disease, cardiovascular disease, diabetes mellitus, rheumatoid arthritis, and lung cancer. We compared the TB-associated genes with genes of its overlapping NCDs to determine the gene-disease relationship. Next, we constructed the gene interaction network of disease-genes by integrating curated and experimentally validated interactions in humans and find the 13 highly clustered modules in the network, which contains a total of 86 hub genes that are commonly associated with TB and its overlapping NCDs, which are largely involved in the Inflammatory response, cellular response to cytokine stimulus, response to cytokine, cytokine-mediated signaling pathway, defense response, response to stress and immune system process. Moreover, the identified hub genes and their respective drugs were exploited to build a bipartite network that assists in deciphering the drug-target interaction, highlighting the influential roles of these drugs on apparently unrelated targets and pathways. Targeting these hub proteins by using drugs combination or drug repurposing approaches will improve the clinical conditions in comorbidity, enhance the potency of a few drugs, and give a synergistic effect with better outcomes. Thus, understanding the Mycobacterium tuberculosis (Mtb) infection and associated NCDs is a high priority to contain its short and long-term effects on human health. Our network-based analysis opens a new horizon for more personalized treatment, drug-repurposing opportunities, investigates new targets, multidrug treatment, and can uncover several side effects of unrelated drugs for TB and its overlapping NCDs.
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Affiliation(s)
- Aftab Alam
- Centre for Interdisciplinary Research in Basic Sciences, Jamia Millia Islamia, New Delhi, India
| | - Hala Abubaker Bagabir
- Department of Physiology, Faculty of Medicine, King Abdulaziz University, Rabigh, Saudi Arabia
| | - Armiya Sultan
- Department of Biosciences, Jamia Millia Islamia, New Delhi, India
| | | | - Nikhat Imam
- Department of Mathematics, Institute of Computer Science and Information Technology, Magadh University, Bodh Gaya, India
| | - Mustfa F Alkhanani
- Emergency Service Department, College of Applied Sciences, AlMaarefa University, Riyadh, Saudi Arabia
| | - Ahmad Alsulimani
- Medical Laboratory Technology Department, College of Applied Medical Sciences, Jazan University, Jazan, Saudi Arabia
| | - Shafiul Haque
- Research and Scientific Studies Unit, College of Nursing and Allied Health Sciences, Jazan University, Jazan, Saudi Arabia
| | - Romana Ishrat
- Centre for Interdisciplinary Research in Basic Sciences, Jamia Millia Islamia, New Delhi, India
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Zhao L, Fang J, Tang S, Deng F, Liu X, Shen Y, Liu Y, Kong F, Du Y, Cui L, Shi W, Wang Y, Wang J, Zhang Y, Dong X, Gao Y, Dong L, Zhou H, Sun Q, Dong H, Peng X, Zhang Y, Cao M, Wang Y, Zhi H, Du H, Zhou J, Li T, Shi X. PM2.5 and Serum Metabolome and Insulin Resistance, Potential Mediation by the Gut Microbiome: A Population-Based Panel Study of Older Adults in China. ENVIRONMENTAL HEALTH PERSPECTIVES 2022; 130:27007. [PMID: 35157499 PMCID: PMC8843086 DOI: 10.1289/ehp9688] [Citation(s) in RCA: 66] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 12/19/2021] [Accepted: 01/03/2022] [Indexed: 05/19/2023]
Abstract
BACKGROUND Insulin resistance (IR) affects the development of type 2 diabetes mellitus (T2DM), which is also influenced by accumulated fine particle air pollution [particulate matter (PM) with aerodynamic diameter of <2.5μm (PM2.5)] exposure. Previous experimental and epidemiological studies have proposed several potential mechanisms by which PM2.5 contributes to IR/T2DM, including inflammation imbalance, oxidative stress, and endothelial dysfunction. Recent evidence suggests that the imbalance of the gut microbiota affects the metabolic process and may precede IR. However, the underlying mechanisms of PM2.5, gut microbiota, and metabolic diseases are unclear. OBJECTIVES We investigated the associations between personal exposure to PM2.5 and fasting blood glucose and insulin levels, the IR index, and other related biomarkers. We also explored the potential underlying mechanisms (systemic inflammation and sphingolipid metabolism) between PM2.5 and insulin resistance and the mediating effects between PM2.5 and sphingolipid metabolism. METHODS We recruited 76 healthy seniors to participate in a repeated-measures panel study and conducted clinical examinations every month from September 2018 to January 2019. Linear mixed-effects (LME) models were used to analyze the associations between PM2.5 and health data (e.g., functional factors, the IR index, inflammation and other IR-related biomarkers, metabolites, and gut microbiota). We also performed mediation analyses to evaluate the effects of mediators (gut microbiota) on the associations between exposures (PM2.5) and featured metabolism outcomes. RESULTS Our prospective panel study illustrated that exposure to PM2.5 was associated with an increased risk of higher IR index and functional biomarkers, and our study provided mechanistic evidence suggesting that PM2.5 exposure may contribute to systemic inflammation and altered sphingolipid metabolism. DISCUSSION Our findings demonstrated that PM2.5 was associated with the genera of the gut microbiota, which partially mediated the association between PM2.5 and sphingolipid metabolism. These findings may extend our current understanding of the pathways of PM2.5 and IR. https://doi.org/10.1289/EHP9688.
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Affiliation(s)
- Liang Zhao
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Jianlong Fang
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Song Tang
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Fuchang Deng
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Xiaohui Liu
- National Protein Science Technology Center and School of Life Sciences, Tsinghua University, Beijing, China
| | - Yu Shen
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Yuanyuan Liu
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Fanling Kong
- Shandong Provincial Center for Disease Control and Prevention, Jinan, Shandong, China
| | - Yanjun Du
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Liangliang Cui
- Jinan Municipal Center for Disease Control and Prevention, Jinan, Shandong, China
| | - Wanying Shi
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Yan Wang
- Shandong Provincial Center for Disease Control and Prevention, Jinan, Shandong, China
| | - Jiaonan Wang
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Yingjian Zhang
- Jinan Municipal Center for Disease Control and Prevention, Jinan, Shandong, China
| | - Xiaoyan Dong
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Ying Gao
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Li Dong
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Huichan Zhou
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Qinghua Sun
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Haoran Dong
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Xiumiao Peng
- Jinan Municipal Center for Disease Control and Prevention, Jinan, Shandong, China
| | - Yi Zhang
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Meng Cao
- Jinan Municipal Center for Disease Control and Prevention, Jinan, Shandong, China
| | - Yanwen Wang
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Hong Zhi
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Hang Du
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Jingyang Zhou
- Shandong Provincial Center for Disease Control and Prevention, Jinan, Shandong, China
| | - Tiantian Li
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Xiaoming Shi
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China
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Carballo I, Alonso-Sampedro M, Gonzalez-Conde E, Sanchez-Castro J, Vidal C, Gude F, Gonzalez-Quintela A. Factors Influencing Total Serum IgE in Adults: The Role of Obesity and Related Metabolic Disorders. Int Arch Allergy Immunol 2020; 182:220-228. [PMID: 33176332 DOI: 10.1159/000510789] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 08/10/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND AIM Few reports have investigated the association between metabolic abnormalities (obesity and related metabolic syndrome) and total serum IgE concentrations. METHODS This cross-sectional study included a random sample of 1,516 adult individuals (44.7% men, aged 18-91 years, median 52 years) from a single municipality in Spain. Serum IgE was measured in the ADVIA Centaur system. Atopy was defined by the presence of positive skin prick tests to a panel of common aeroallergens in the area. Body mass index and data related to the definition of metabolic syndrome were obtained from all participants. Alcohol consumption, smoking, and regular physical exercise were assessed by a questionnaire. RESULTS Atopy (present in 21.9% of 1,514 evaluable individuals) was the strongest factor determining serum IgE concentrations. Male sex and heavy alcohol drinking were independently associated with higher IgE concentrations, particularly in the non-atopic individuals. Body mass index was positively associated with IgE concentrations, independent of potential confounders, although the effect was only evident among non-atopic individuals. In that group, median IgE concentrations in normal-weight and obese individuals were 15 and 24 kU/L, respectively (p < 0.001); likewise, obesity was associated with high (>100 kU/L) IgE concentrations after adjusting for potential confounders (odds ratio: 1.79, 95% confidence interval: 1.26-2.56, p = 0.001). The presence of metabolic syndrome and its components, particularly abdominal obesity and hyperglycaemia, was also positively and independently associated with higher IgE concentrations in non-atopic individuals. CONCLUSIONS Obesity and metabolic syndrome components are associated with high total serum IgE concentrations, particularly in non-atopic individuals.
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Affiliation(s)
- Iago Carballo
- Department of Internal Medicine, Complejo Hospitalario Universitario, Instituto de Investigaciones Sanitarias of Santiago de Compostela, Santiago de Compostela, Spain
| | - Manuela Alonso-Sampedro
- Department of Clinical Epidemiology, Complejo Hospitalario Universitario, Instituto de Investigaciones Sanitarias of Santiago de Compostela, Santiago de Compostela, Spain
| | - Elena Gonzalez-Conde
- Department of Internal Medicine, Complejo Hospitalario Universitario, Instituto de Investigaciones Sanitarias of Santiago de Compostela, Santiago de Compostela, Spain
| | | | - Carmen Vidal
- Department of Allergy, Complejo Hospitalario Universitario, Instituto de Investigaciones Sanitarias of Santiago de Compostela, Santiago de Compostela, Spain
| | - Francisco Gude
- Department of Clinical Epidemiology, Complejo Hospitalario Universitario, Instituto de Investigaciones Sanitarias of Santiago de Compostela, Santiago de Compostela, Spain
| | - Arturo Gonzalez-Quintela
- Department of Internal Medicine, Complejo Hospitalario Universitario, Instituto de Investigaciones Sanitarias of Santiago de Compostela, Santiago de Compostela, Spain,
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