1
|
Chen H, Liu L, Wang Y, Hong L, Pan J, Yu X, Dai H. Managing Cardiovascular Risk in Patients with Autoimmune Diseases: Insights from a Nutritional Perspective. Curr Nutr Rep 2024:10.1007/s13668-024-00563-7. [PMID: 39078574 DOI: 10.1007/s13668-024-00563-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2024] [Indexed: 07/31/2024]
Abstract
PURPOSE OF REVIEW Autoimmune diseases manifest as an immune system response directed against endogenous antigens, exerting a significant influence on a substantial portion of the population. Notably, a leading contributor to morbidity and mortality in this context is cardiovascular disease (CVD). Intriguingly, individuals with autoimmune disorders exhibit a heightened prevalence of CVD compared to the general population. The meticulous management of CV risk factors assumes paramount importance, given the current absence of a standardized solution to this perplexity. This review endeavors to address this challenge from a nutritional perspective. RECENT FINDINGS Emerging evidence suggests that inflammation, a common thread in autoimmune diseases, also plays a pivotal role in the pathogenesis of CVD. Nutritional interventions aimed at reducing inflammation have shown promise in mitigating cardiovascular risk. The integration of nutritional strategies into the management plans for patients with autoimmune diseases offers a holistic approach to reducing cardiovascular risk. While conventional pharmacological treatments remain foundational, the addition of targeted dietary interventions can provide a complementary pathway to improve cardiovascular outcomes.
Collapse
Affiliation(s)
- Huimin Chen
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, China
- State Key Laboratory of Transvascular Implantation Devices, Hangzhou, 310009, China
| | - Lu Liu
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, China
- State Key Laboratory of Transvascular Implantation Devices, Hangzhou, 310009, China
| | - Yi Wang
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, China
- State Key Laboratory of Transvascular Implantation Devices, Hangzhou, 310009, China
| | - Liqiong Hong
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, China
- State Key Laboratory of Transvascular Implantation Devices, Hangzhou, 310009, China
| | - Jiahui Pan
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, China
- State Key Laboratory of Transvascular Implantation Devices, Hangzhou, 310009, China
| | - Xiongkai Yu
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, China
- State Key Laboratory of Transvascular Implantation Devices, Hangzhou, 310009, China
| | - Haijiang Dai
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, China.
- State Key Laboratory of Transvascular Implantation Devices, Hangzhou, 310009, China.
| |
Collapse
|
2
|
Salmon J, Wallace DJ, Rus V, Cox A, Dykas C, Williams B, Ding Y, Hals PA, Johnsen L, Lipsky PE. Correction of omega-3 fatty acid deficiency and improvement in disease activity in patients with systemic lupus erythematosus treated with krill oil concentrate: a multicentre, randomised, double-blind, placebo-controlled trial. Lupus Sci Med 2024; 11:e001201. [PMID: 39009356 PMCID: PMC11268053 DOI: 10.1136/lupus-2024-001201] [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: 03/08/2024] [Accepted: 06/07/2024] [Indexed: 07/17/2024]
Abstract
OBJECTIVE Omega-3 polyunsaturated fatty acids (PUFAs) play a critical role in regulating inflammation and lipid metabolism. This study sought to ascertain the frequency of omega-3 deficiency in patients with SLE and investigate whether supplementation with krill oil concentrate (KOC) could replenish omega-3 levels and decrease SLE disease activity. METHODS A multicentre, randomised, double-blind, placebo-controlled trial was conducted in adult patients with active SLE. Eligible patients were randomised to receive 4 g/day KOC or placebo (vegetable oil mixture) for the first 24 weeks, and thereafter patients could opt to enter an open-label extension. The primary end point was improvement of the red blood cell Omega-3 Index from baseline to week 24. Changes in clinical features, including SLE Disease Activity Index 2000 (SLEDAI-2K) disease activity scores, were also monitored. RESULTS Seventy-eight patients met eligibility criteria and were randomised to a treatment group (n=39 per group). The baseline Omega-3 Index in the total SLE cohort was a mean 4.43% (±SD 1.04%). After 4 weeks of KOC treatment, the Omega-3 Index rapidly increased to 7.17%±1.48% (n=38) and after 24 weeks to 8.05%±1.79% (n=25) (each p<0.001 vs baseline), whereas no significant change from baseline was noted in patients receiving placebo. Increases in the Omega-3 Index in KOC-treated patients persisted through week 48. After patients switched from placebo to KOC at 24 weeks, the mean Omega-3 Index showed a rapid and significant increase (from 4.63%±1.39% at week 24 (n=26) to 7.50%±1.75% at week 48 (n=12); p<0.001). Although there were no changes in disease activity in the study population overall, SLEDAI-2K scores decreased significantly in the KOC group during the 24-week randomised period among those who had high disease activity at baseline (SLEDAI-2K ≥9) (p=0.04, p=0.02 and p=0.01 vs placebo at 4, 8 and 16 weeks, respectively; n=9 per group). KOC was well-tolerated, with no significant safety concerns. CONCLUSION KOC corrected omega-3 deficiency in patients with SLE. Supplementation with KOC was safe and decreased disease activity in those with more active disease. These findings warrant further evaluation of omega-3 fatty acid supplementation with KOC in the management of SLE. TRIAL REGISTRATION NUMBER NCT03626311.
Collapse
Affiliation(s)
- Jane Salmon
- Rheumatology, Hospital for Special Surgery, New York City, New York, USA
| | - Daniel J Wallace
- Rheumatology, Cedars-Sinai Medical Center, West Hollywood, California, USA
| | - Violeta Rus
- Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Addison Cox
- AMPEL BioSolutions LLC, Charlottesville, Virginia, USA
| | - Claire Dykas
- AMPEL BioSolutions LLC, Charlottesville, Virginia, USA
| | | | - Yunpeng Ding
- Aker BioMarine Human Ingredients AS, Lysaker, Norway
| | | | - Line Johnsen
- Aker BioMarine Human Ingredients AS, Lysaker, Norway
| | | |
Collapse
|
3
|
Wang B, Wang H, Huang J, Zhao T. Association between Unsaturated Fatty Acid-Type Diet and Systemic Lupus Erythematosus: A Systematic Review with Meta-Analyses. Nutrients 2024; 16:1974. [PMID: 38931327 PMCID: PMC11206385 DOI: 10.3390/nu16121974] [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] [Received: 05/23/2024] [Revised: 06/17/2024] [Accepted: 06/18/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND Systemic lupus erythematosus (SLE) is a complex autoimmune disorder that affects multiple organ systems, with a higher prevalence among women in their reproductive years. The disease's multifactorial etiology involves genetic, environmental, and hormonal components. Recent studies have highlighted the potential impact of dietary factors, particularly unsaturated fatty acids, on the modulation of SLE due to their anti-inflammatory properties. This meta-analysis aims to evaluate the association between unsaturated fatty acid consumption and the risk, progression, and clinical manifestations of SLE, providing evidence-based guidance for dietary management. METHODS We conducted a comprehensive search across major medical databases up to January 2024, focusing on studies that examined the intake of unsaturated fatty acids and the impact of such intake on SLE. Using the PICOS (population, intervention, comparator, outcomes, study design) framework, we included randomized controlled trials and case-control studies, assessing outcomes such as SLE activity, measured by SLE Disease Activity Index (SLEDAI) or the British Isles Lupus Assessment Group (BILAG) index, inflammation biomarkers. Studies were analyzed using either a fixed- or random-effects model based on heterogeneity (I2 statistic), with sensitivity analyses performed to assess the robustness of the findings. RESULTS Our search included 10 studies, encompassing a wide variety of designs and populations. The meta-analysis showed that a diet rich in unsaturated fatty acids is significantly associated with a reduction in SLEDAI scores (pooled SMD) of -0.36, 95% CI: -0.61 to -0.11, p = 0.007, indicating a beneficial effect on disease activity. Additionally, we found that unsaturated fatty acid intake has a significant impact on HDL levels, suggesting a positive effect on lipid profiles. However, no significant effects were observed on levels of the inflammatory marker IL-6 or other lipid components (LDL and cholesterol). With minimal heterogeneity among studies (I2 ≤ 15%), sensitivity analysis confirmed the stability and reliability of these results, highlighting the potential role of unsaturated fatty acids in SLE management. CONCLUSIONS This meta-analysis suggests that dietary intake of unsaturated fatty acids may play a positive role in reducing SLE activity and may significantly affect HDL levels without having significant effects on inflammation markers or other lipid profiles. These findings support the inclusion of unsaturated fatty acids in the dietary management of SLE patients, although further research is required to refine dietary recommendations and explore the mechanisms underlying these associations.
Collapse
Affiliation(s)
- Bozhou Wang
- The First School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou 310053, China; (B.W.); (H.W.); (J.H.)
| | - Hanzheng Wang
- The First School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou 310053, China; (B.W.); (H.W.); (J.H.)
| | - Jinge Huang
- The First School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou 310053, China; (B.W.); (H.W.); (J.H.)
| | - Ting Zhao
- Key Laboratory of Chinese Medicine Rheumatology of Zhejiang Province, Research Institute of Chinese Medical Clinical Foundation and Immunology, College of Basic Medical Science, Zhejiang Chinese Medical University, Hangzhou 310053, China
| |
Collapse
|
4
|
Stubbs A, Clauw DJ. Nutrients and Nocioception: Diet in the management of pain. Best Pract Res Clin Rheumatol 2024; 38:101963. [PMID: 38918099 DOI: 10.1016/j.berh.2024.101963] [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] [Received: 05/10/2024] [Accepted: 05/16/2024] [Indexed: 06/27/2024]
Abstract
Nutrition can play a pivotal role in the management of pain associated with chronic rheumatic diseases. There is a growing body of research linking certain nutrients from the diet to inflammation. Certain nutrients have been shown to improve pain associated with inflammation. Furthermore, certain dietary patterns have been shown to improve pain across multiple rheumatic conditions. Finally, maintaining a low body mass is associated with improved pain associated with chronic rheumatic diseases.
Collapse
Affiliation(s)
- Aaron Stubbs
- Department of Rheumatology, Michigan Medicine, United States.
| | - Daniel J Clauw
- Chronic Pain and Fatigue Research Center, Department of Anesthesiology, Michigan Medicine, United States
| |
Collapse
|
5
|
Goldner B, Staffier KL. Case series: raw, whole, plant-based nutrition protocol rapidly reverses symptoms in three women with systemic lupus erythematosus and Sjögren's syndrome. Front Nutr 2024; 11:1208074. [PMID: 38505266 PMCID: PMC10949923 DOI: 10.3389/fnut.2024.1208074] [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: 04/18/2023] [Accepted: 01/05/2024] [Indexed: 03/21/2024] Open
Abstract
Systemic lupus erythematosus (SLE) and Sjögren's syndrome (SS) are chronic autoimmune diseases. Symptoms of SLE can vary widely but often include fatigue, pain, photosensitivity, and, in some cases, nephritis. SS is frequently characterized by extreme dry eye and mouth, resulting from damage to moisture-producing glands, and is often present in combination with SLE. While the health benefits of plant-based diets have been well-established with respect to weight and cardiometabolic outcomes, less research is available to support the role of diet in treatment and management of autoimmune disease. This case series presents three women with SLE and SS who adopted a nutrition protocol to reverse symptoms of autoimmune disease. The protocol emphasizes leafy greens, cruciferous vegetables, omega-3 polyunsaturated fatty acids, and water, and includes predominately raw foods. The three patients reported dramatic improvements in physical symptoms, with nearly all symptoms of SLE and SS resolving after 4 weeks or less of adhering to the protocol. All three patients have remained symptom-free, two of whom have remained symptom-free for 6+ years with no recent medication use. Patients and practitioners should be made aware of the promising possibility of food as medicine in the treatment of SLE and SS. Future research should explore whether dietary changes may be a potential treatment strategy for individuals suffering from severe symptoms and poor quality of life due to SLE and SS.
Collapse
|
6
|
Liu A, Li Z, Zeng J, Peng Y, Wang S, Bi X, Zhao Z, Zhou S, Zhao AZ, Mu Y, Li F. ω-3 polyunsaturated fatty acid alleviates systemic lupus erythematosus by suppressing autoimmunity in a murine model. Int Immunopharmacol 2024; 126:111299. [PMID: 38043268 DOI: 10.1016/j.intimp.2023.111299] [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] [Received: 08/24/2023] [Revised: 11/24/2023] [Accepted: 11/24/2023] [Indexed: 12/05/2023]
Abstract
Systemic lupus erythematosus (SLE) is a heterogeneous autoimmune inflammatory disease that damages multiple organs by the production of autoantibodies. Numerous research studies have demonstrated the anti-inflammatory effects of ω-3 polyunsaturated fatty acids (PUFAs). A diet rich in ω-3 PUFAs reduces chronic inflammatory and autoimmune conditions. Herein, we investigated the protective effect of ω-3 PUFAs against autoimmune injury in SLE. In a TMPD-induced mouse model of SLE, supplementation with eicosapentaenoic acid (EPA)-rich (97%) fish oil was found to alleviate systemic autoimmune phenotypes such as ascites, lipogranulomas and serum dsDNA levels. In addition, EPA also significantly improved renal manifestations, reducing proteinuria, glomerulonephritis, and immune complex deposition. Mechanistically, ω-3 PUFAs were shown to modulate the differentiation of B lymphocyte subsets of primary splenic lymphocytes in the spontaneous murine lupus model MRL/MpJ-Faslpr in vitro, specifically that both EPA and DHA suppressed the number of total B cells, B1B2 cells and plasma cells. Concurrently, they were also found to promote the secretion of the anti-inflammatory cytokine IL10, mainly produced by Breg and Treg cells. Thus, nutritional supplementation with ω-3 PUFAs can regulate B cell's differentiation and anti-inflammatory function and strongly prevent autoimmune responses and lupus nephritis. The diets balance between ω-6 and ω-3 PUFAs intake may represent a promising treatment strategy to prevent or delay the onset of SLE.
Collapse
Affiliation(s)
- Aolu Liu
- School of Biomedical and Pharmaceutical Sciences, Guangdong University of Technology, Guangzhou 510006, China
| | - Zhuang Li
- School of Biomedical and Pharmaceutical Sciences, Guangdong University of Technology, Guangzhou 510006, China
| | - Jingwen Zeng
- School of Biomedical and Pharmaceutical Sciences, Guangdong University of Technology, Guangzhou 510006, China
| | - Yuerong Peng
- School of Biomedical and Pharmaceutical Sciences, Guangdong University of Technology, Guangzhou 510006, China
| | - Shuai Wang
- School of Biomedical and Pharmaceutical Sciences, Guangdong University of Technology, Guangzhou 510006, China
| | - Xinyun Bi
- School of Biomedical and Pharmaceutical Sciences, Guangdong University of Technology, Guangzhou 510006, China
| | - Zhenggang Zhao
- School of Biomedical and Pharmaceutical Sciences, Guangdong University of Technology, Guangzhou 510006, China
| | - Sujin Zhou
- School of Biomedical and Pharmaceutical Sciences, Guangdong University of Technology, Guangzhou 510006, China
| | - Allan Zijian Zhao
- School of Biomedical and Pharmaceutical Sciences, Guangdong University of Technology, Guangzhou 510006, China
| | - Yunping Mu
- School of Biomedical and Pharmaceutical Sciences, Guangdong University of Technology, Guangzhou 510006, China.
| | - Fanghong Li
- School of Biomedical and Pharmaceutical Sciences, Guangdong University of Technology, Guangzhou 510006, China.
| |
Collapse
|
7
|
Nutritional Approaches to Modulate Cardiovascular Disease Risk in Systemic Lupus Erythematosus: A Literature Review. Nutrients 2023; 15:nu15041036. [PMID: 36839394 PMCID: PMC9958972 DOI: 10.3390/nu15041036] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 02/15/2023] [Accepted: 02/17/2023] [Indexed: 02/22/2023] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic pathology characterized by a bimodal mortality pattern attributed to clinical disease activity and cardiovascular disease (CVD). A complex interaction between traditional CVD risk factors such as obesity, dyslipidemia, smoking, insulin resistance, metabolic syndrome, and hypertension, as well as the presence of non-traditional CVD risk factors such as hyperhomocysteinemia, pro-inflammatory cytokines, and C-reactive protein levels, has been suggested as a cause of the high prevalence of CVD in SLE patients. On the other hand, environmental factors, such as nutritional status, could influence the disease's prognosis; several nutrients have immunomodulators, antioxidants, and anti-cardiometabolic risk properties which could reduce SLE severity and organ damage by decreasing the development of traditional and non-traditional CVD risk factors. Therefore, this critical literature review discusses the therapeutic potential of nutritional approaches that could modulate the development of the main comorbidities related to CVD risk in SLE patients.
Collapse
|
8
|
Salek M, Hosseini Hooshiar S, Salek M, Poorebrahimi M, Jafarnejad S. Omega-3 fatty acids: Current insights into mechanisms of action in systemic lupus erythematosus. Lupus 2023; 32:7-22. [PMID: 36433776 DOI: 10.1177/09612033221140724] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Systemic lupus erythematosus (SLE) is one of the autoimmune diseases characterized by the lack of self-tolerance and the formation of immune complexes and nuclear autoantigens resulting in inflammation in multiple organs. Nowadays, the major aim of SLE therapy is the control of disease activity. However, the biological heterogeneity between patients and the absence of safe and specific targeted treatments complicate the lupus management. Therefore, the potential prophylactic effects of natural therapy considering the potential side effects of classical pharmacology, also the role of diet therapy in decreasing co-morbidities and improving quality of life in SLE patients could be a promising approach to SLE disease. Omega-3 polyunsaturated fatty acids (omega-3 PUFAs) are one of the agents that are considered for their preventive and therapeutic properties in disease activity of SLE and the related complications. The intake of omega-3 PUFAs likely has a direct relationship with improvements in inflammatory, cardiovascular, depressive, and neuromotor symptoms of the patients. The current review summarizes clinical and preclinical studies with comprehensive insights into the mechanisms of action of omega-3 fatty acids (omega-3 FAs) in Systemic Lupus Erythematosus to provide an update on the negative and positive aspects of the intake of omega-3 FAs in SLE patients.
Collapse
Affiliation(s)
- Mina Salek
- Department of Nutrition, School of Public Health, 440827Iran University of Medical Sciences, Tehran, Iran
| | - Saeedeh Hosseini Hooshiar
- Research Center for Biochemistry and Nutrition in Metabolic Diseases, 48462Kashan University of Medical Sciences, Kashan, Iran
| | - Mahsa Salek
- Department of Medicine, 201564Islamic Azad University Najafabad Branch, Najafabad, Iran
| | - Mohsen Poorebrahimi
- Research Center for Biochemistry and Nutrition in Metabolic Diseases, 48462Kashan University of Medical Sciences, Kashan, Iran
| | - Sadegh Jafarnejad
- Research Center for Biochemistry and Nutrition in Metabolic Diseases, 48462Kashan University of Medical Sciences, Kashan, Iran
| |
Collapse
|
9
|
Jiao H, Acar G, Robinson GA, Ciurtin C, Jury EC, Kalea AZ. Diet and Systemic Lupus Erythematosus (SLE): From Supplementation to Intervention. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:11895. [PMID: 36231195 PMCID: PMC9565311 DOI: 10.3390/ijerph191911895] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 09/12/2022] [Accepted: 09/13/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Systemic lupus erythematosus (SLE) is a chronic autoimmune inflammatory disease characterised by immune dysregulation affecting multiple organs. Current anti-inflammatory treatments used in SLE are associated with unwanted side-effects. Dietary supplementation has been suggested as a safe and effective addition to conventional treatment, but evidence of efficacy in SLE or preventing associated comorbidities is uncertain. METHODS We identified literature on clinical trials focused on nutritional interventions in SLE aiming to improve inflammation and comorbidities. A systematic-type search on Embase, Medline, and the Cochrane Library, was conducted to identify nutritional interventions among SLE patients in the past 15 years that met our inclusion criteria. RESULTS We identified 2754 articles, of which 14 were eligible for inclusion based on our set criteria and were subsequently quality assessed. Vitamin D or E supplementation was associated with respective improvement of inflammatory markers or antibody production, but not disease activity scores in most studies. Despite their expected synergistic actions, the addition of curcumin on vitamin D supplementation had no additional effects on disease activity or inflammatory markers. Trials of omega-3 fatty acid supplementation presented significant reductions in ESR, CRP, disease activity, inflammatory markers, and oxidative stress, and improved lipid levels and endothelial function, while a low glycaemic index (GI) diet showed evidence of reduced weight and improved fatigue in patients. CONCLUSIONS Different dietary guidelines can therefore be implicated to target specific SLE symptoms or therapeutic side-effects. This systematic review highlights the scarcity of larger and longer in duration trials with homogenous methodologies and verifiable outcomes to assess disease progression.
Collapse
Affiliation(s)
- Hanxiao Jiao
- Division of Medicine, University College London, Rayne Building, London WC1E 6JF, UK
| | - Gizem Acar
- Division of Medicine, University College London, Rayne Building, London WC1E 6JF, UK
| | - George A. Robinson
- Centre for Rheumatology Research, Division of Medicine, University College London, Rayne Building, London W1CE 6JF, UK
- Centre for Adolescent Rheumatology versus Arthritis, Division of Medicine, University College London, Rayne Building, London W1CE 6JF, UK
| | - Coziana Ciurtin
- Centre for Adolescent Rheumatology versus Arthritis, Division of Medicine, University College London, Rayne Building, London W1CE 6JF, UK
| | - Elizabeth C. Jury
- Centre for Rheumatology Research, Division of Medicine, University College London, Rayne Building, London W1CE 6JF, UK
| | - Anastasia Z. Kalea
- Division of Medicine, University College London, Rayne Building, London WC1E 6JF, UK
- Institute of Cardiovascular Science, University College London, London WC1E 6DD, UK
| |
Collapse
|
10
|
Gwinnutt JM, Wieczorek M, Rodríguez-Carrio J, Balanescu A, Bischoff-Ferrari HA, Boonen A, Cavalli G, de Souza S, de Thurah A, Dorner TE, Moe RH, Putrik P, Silva-Fernández L, Stamm T, Walker-Bone K, Welling J, Zlatković-Švenda M, Guillemin F, Verstappen SMM. Effects of diet on the outcomes of rheumatic and musculoskeletal diseases (RMDs): systematic review and meta-analyses informing the 2021 EULAR recommendations for lifestyle improvements in people with RMDs. RMD Open 2022; 8:rmdopen-2021-002167. [PMID: 35654458 PMCID: PMC9096533 DOI: 10.1136/rmdopen-2021-002167] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 04/01/2022] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND A EULAR taskforce was convened to develop recommendations for lifestyle behaviours in rheumatic and musculoskeletal diseases (RMDs). In this paper, the literature on the effect of diet on the progression of RMDs is reviewed. METHODS Systematic reviews and meta-analyses were performed of studies related to diet and disease outcomes in seven RMDs: osteoarthritis (OA), rheumatoid arthritis (RA), systemic lupus erythematosus, axial spondyloarthritis, psoriatic arthritis, systemic sclerosis and gout. In the first phase, existing relevant systematic reviews and meta-analyses, published from 2013 to 2018, were identified. In the second phase, the review was expanded to include published original studies on diet in RMDs, with no restriction on publication date. Systematic reviews or original studies were included if they assessed a dietary exposure in one of the above RMDs, and reported results regarding progression of disease (eg, pain, function, joint damage). RESULTS In total, 24 systematic reviews and 150 original articles were included. Many dietary exposures have been studied (n=83), although the majority of studies addressed people with OA and RA. Most dietary exposures were assessed by relatively few studies. Exposures that have been assessed by multiple, well conducted studies (eg, OA: vitamin D, chondroitin, glucosamine; RA: omega-3) were classified as moderate evidence of small effects on disease progression. CONCLUSION The current literature suggests that there is moderate evidence for a small benefit for certain dietary components. High-level evidence of clinically meaningful effect sizes from individual dietary exposures on outcomes in RMDs is missing.
Collapse
Affiliation(s)
- James M Gwinnutt
- Centre for Epidemiology Versus Arthritis, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Maud Wieczorek
- EA 4360 Apemac, Université de Lorraine, Nancy, France,Center on Aging and Mobility, University of Zurich, Zurich, Switzerland
| | - Javier Rodríguez-Carrio
- Area of Immunology, Department of Functional Biology, Universidad de Oviedo, Oviedo, Spain,Department of Metabolism, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Andra Balanescu
- Department of Internal Medicine and Rheumatology, ‘Sf Maria’ Hospital, ‘Carol Davila’ University of Medicine and Pharmacy, Bucharest, Romania
| | - Heike A Bischoff-Ferrari
- Center on Aging and Mobility, University of Zurich, Zurich, Switzerland,Department of Aging Medicine and Aging Research, University Hospital Zurich and University of Zurich, Zurich, Switzerland,University Clinic for Aging Medicine, City Hospital Zurich - Waid, Zurich, Switzerland
| | - Annelies Boonen
- Department of Internal Medicine, Division of Rheumatology, Maastricht University Medical Center, Maastricht, The Netherlands,Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Giulio Cavalli
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital and Vita-Salute San Raffaele University, Milan, Italy
| | - Savia de Souza
- Centre for Rheumatic Diseases, King's College London, London, UK
| | - Annette de Thurah
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark,Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
| | - Thomas E Dorner
- Centre for Public Health, Department of Social and Preventive Medicine, Medical University of Vienna, Vienna, Austria,Social Insurance Fund for Public Service, Railway and Mining Industries, Sitzenberg-Reidling, Austria,Karl-Landsteiner Institute for Health Promotion Research, Sitzenberg-Reidling, Austria
| | - Rikke Helene Moe
- National Advisory Unit for Rehabilitation in Rheumatology, Division of Rheumatology and Research, Diakonhjemmet Hospital, Oslo, Norway
| | - Polina Putrik
- Department of Internal Medicine, Division of Rheumatology, Maastricht University Medical Center, Maastricht, The Netherlands,Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Lucía Silva-Fernández
- Rheumatology Department, Hospital Universitari Son Espases, Palma de Mallorca, Spain
| | - Tanja Stamm
- Section for Outcomes Research, Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria,Ludwig Boltzmann Institute for Arthritis and Rehabilitation, Vienna, Austria
| | - Karen Walker-Bone
- MRC Versus Arthritis Centre for Musculoskeletal Health and Work, University of Southampton, Southampton, UK
| | - Joep Welling
- NVLE Dutch Patient Organization for Systemic Autoimmune Diseases, Utrecht, The Netherlands
| | - Mirjana Zlatković-Švenda
- Institute of Rheumatology, University of Belgrade School of Medicine, Belgrade, Serbia,Department of Internal Medicine, University of East Sarajevo Faculty of Medicine Foča, Republika Srpska, Bosnia and Herzegovina
| | - Francis Guillemin
- EA 4360 Apemac, Université de Lorraine, Nancy, France,Inserm, CHRU Nancy, CIC-1433 Epidémiologie Clinique, Université de Lorraine, Nancy, France
| | - Suzanne M M Verstappen
- Centre for Epidemiology Versus Arthritis, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK .,MRC Versus Arthritis Centre for Musculoskeletal Health and Work, University of Southampton, Southampton, UK.,NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| |
Collapse
|
11
|
Shi H, Ter Horst R, Nielen S, Bloemendaal M, Jaeger M, Joosten I, Koenen H, Joosten LAB, Schweren LJS, Vasquez AA, Netea MG, Buitelaar J. The gut microbiome as mediator between diet and its impact on immune function. Sci Rep 2022; 12:5149. [PMID: 35338162 PMCID: PMC8956630 DOI: 10.1038/s41598-022-08544-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 02/18/2022] [Indexed: 12/22/2022] Open
Abstract
Dietary habits may affect inflammatory status in humans. Here we explore this interaction as well as the potential mediating role of the gut microbiome (GM), given that the GM is both involved in processing of dietary components and influences the immune system. A cross-sectional analysis of a sample of 482 healthy participants (207 males and 275 females) was performed. Dietary intake was assessed by a semiquantitative food questionnaire. Adipokines and soluble inflammatory mediators were assayed with multiple immunoassays and ELISA. Microbial DNA was extracted from frozen stool samples of 471 participants. Polychoric correlation analysis was used to establish dietary patterns, and joint multivariate associations between these dietary patterns and immune biomarkers were studied using regression analyses with adjustment for sex, age, BMI, smoking, education levels and physical exercise and other dietary patterns. Non-parametric entropy mediation was applied to investigate whether diet-immune relationships are mediated by abundance of microbial species. In this cohort, we identified three dietary patterns, characterized as “high-meat” (meat and sweetened drink), “prudent diet” (fish, fruit, legumes and vegetables) and “high alcohol” (higher alcohol consumption). Higher adherence to prudent diet was associated with a higher adiponectin level. The high alcohol pattern was associated with high concentrations of circulating concentrations of pro-inflammatory markers (CRP, IL-6, VEGF). Dialister invisus was found to mediate the relationship between a prudent dietary pattern and adiponectin, AAT, CRP, IL-6, and VEGF. In conclusion, a meat-based diet and a diet with high alcohol consumption were associated with high concentrations of biomarkers of chronic low-grade inflammation, and conversely, a prudent diet was associated with anti-inflammatory biomarkers. Diet-inflammation regulation may differ between sexes. Mediation analyses revealed that the association between prudent diet and immune function was partially mediated by the GM. The study adds to our understanding of the associations between diet, the immune system and the GM in a healthy population.
Collapse
Affiliation(s)
- Huiqing Shi
- Department of Cognitive Neuroscience, Donders Institute for Brain, Cognition and Behaviour, Radboud University Nijmegen Medical Centre, Radboudumc, Kapittelweg 29, 6525 EN, Nijmegen, Gelderland, The Netherlands.
| | - Rob Ter Horst
- Department of Internal Medicine, Radboudumc Center for Infectious Diseases, Radboudumc, 6500 HB, Nijmegen, Gelderland, The Netherlands
| | - Suzanne Nielen
- Department of Psychiatry, and Department of Genetics, Donders Institute for Brain, Cognition and Behaviour, Radboudumc, 6525 EN, Nijmegen, Gelderland, The Netherlands
| | - Mirjam Bloemendaal
- Department of Psychiatry, and Department of Genetics, Donders Institute for Brain, Cognition and Behaviour, Radboudumc, 6525 EN, Nijmegen, Gelderland, The Netherlands
| | - Martin Jaeger
- Department of Internal Medicine, Radboudumc Center for Infectious Diseases, Radboudumc, 6500 HB, Nijmegen, Gelderland, The Netherlands
| | - Irma Joosten
- Department of Laboratory Medicine, Radboudumc, 6500 HB, Nijmegen, Gelderland, The Netherlands
| | - Hans Koenen
- Department of Laboratory Medicine, Radboudumc, 6500 HB, Nijmegen, Gelderland, The Netherlands
| | - Leo A B Joosten
- Department of Internal Medicine, Radboudumc Center for Infectious Diseases, Radboudumc, 6500 HB, Nijmegen, Gelderland, The Netherlands
| | - Lizanne J S Schweren
- Interdisciplinary Center Psychopathology and Emotion Regulation, University Medical Center Groningen, University of Groningen, 9700 RB, Hanzeplein 1, Groningen, The Netherlands
| | - Alejandro Arias Vasquez
- Department of Psychiatry, and Department of Genetics, Donders Institute for Brain, Cognition and Behaviour, Radboudumc, 6525 EN, Nijmegen, Gelderland, The Netherlands
| | - Mihai G Netea
- Department of Internal Medicine, Radboudumc Center for Infectious Diseases, Radboudumc, 6500 HB, Nijmegen, Gelderland, The Netherlands.,Department of Immunology and Metabolism, Life and Medical Sciences Institute (LIMES), University of Bonn, Bonn, Germany
| | - Jan Buitelaar
- Department of Cognitive Neuroscience, Donders Institute for Brain, Cognition and Behaviour, Radboud University Nijmegen Medical Centre, Radboudumc, Kapittelweg 29, 6525 EN, Nijmegen, Gelderland, The Netherlands.,Karakter Child and Adolescent Psychiatry University Centre, 6525 GC, Nijmegen, Gelderland, The Netherlands
| |
Collapse
|
12
|
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.
Collapse
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
| |
Collapse
|
13
|
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.
Collapse
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
| |
Collapse
|
14
|
Adiponectin Deregulation in Systemic Autoimmune Rheumatic Diseases. Int J Mol Sci 2021; 22:ijms22084095. [PMID: 33920997 PMCID: PMC8071452 DOI: 10.3390/ijms22084095] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 04/08/2021] [Accepted: 04/13/2021] [Indexed: 02/06/2023] Open
Abstract
Deregulation of adiponectin is found in systemic autoimmune rheumatic diseases (SARDs). Its expression is downregulated by various inflammatory mediators, but paradoxically, elevated serum levels are present in SARDs with high inflammatory components, such as rheumatoid arthritis and systemic lupus erythematosus. Circulating adiponectin is positively associated with radiographic progression in rheumatoid arthritis as well as with cardiovascular risks and lupus nephritis in systemic lupus erythematosus. However, in SARDs with less prominent inflammation, such as systemic sclerosis, adiponectin levels are low and correlate negatively with disease activity. Regulators of adiponectin gene expression (PPAR-γ, Id3, ATF3, and SIRT1) and inflammatory cytokines (interleukin 6 and tumor necrosis factor α) are differentially expressed in SARDs and could therefore influence total adiponectin levels. In addition, anti-inflammatory therapy could also have an impact, as tocilizumab treatment is associated with increased serum adiponectin. However, anti-tumor necrosis factor α treatment does not seem to affect its levels. Our review provides an overview of studies on adiponectin levels in the bloodstream and other biological samples from SARD patients and presents some possible explanations why adiponectin is deregulated in the context of therapy and gene regulation.
Collapse
|
15
|
Chen W, Wang Q, Zhou B, Zhang L, Zhu H. Lipid Metabolism Profiles in Rheumatic Diseases. Front Pharmacol 2021; 12:643520. [PMID: 33897433 PMCID: PMC8064727 DOI: 10.3389/fphar.2021.643520] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 02/18/2021] [Indexed: 12/25/2022] Open
Abstract
Rheumatic diseases are a group of chronic autoimmune disorders that involve multiple organs or systems and have high mortality. The mechanisms of these diseases are still ill-defined, and targeted therapeutic strategies are still challenging for physicians. Recent research indicates that cell metabolism plays important roles in the pathogenesis of rheumatic diseases. In this review, we mainly focus on lipid metabolism profiles (dyslipidaemia, fatty acid metabolism) and mechanisms in rheumatic diseases and discuss potential clinical applications based on lipid metabolism profiles.
Collapse
Affiliation(s)
- Weilin Chen
- Department of Rheumatology, Xiangya Hospital, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha, China.,Provincial Clinical Research Center for Rheumatic and Immunologic Diseases, Xiangya Hospital, Changsha, China
| | - Qi Wang
- Department of Radiology, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, China
| | - Bin Zhou
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Lihua Zhang
- Department of Rheumatology, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, China
| | - Honglin Zhu
- Department of Rheumatology, Xiangya Hospital, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha, China.,Provincial Clinical Research Center for Rheumatic and Immunologic Diseases, Xiangya Hospital, Changsha, China
| |
Collapse
|
16
|
Dessie G, Ayelign B, Akalu Y, Shibabaw T, Molla MD. Effect of Leptin on Chronic Inflammatory Disorders: Insights to Therapeutic Target to Prevent Further Cardiovascular Complication. Diabetes Metab Syndr Obes 2021; 14:3307-3322. [PMID: 34305402 PMCID: PMC8296717 DOI: 10.2147/dmso.s321311] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 06/30/2021] [Indexed: 01/08/2023] Open
Abstract
In response to obesity-associated chronic inflammatory disorders, adipose tissue releases a biologically active peptide known as leptin. Leptin activates the secretion of chemical mediators, which contribute to the pathogenesis of chronic inflammatory disorders, such as rheumatoid arthritis (RA), systemic lupus erythematosus (SLE) and psoriasis. Conversely, adiposity and obesity are the major aggravating risk factors in the pathogenesis of metabolic syndrome (MetS), including type II diabetes mellitus and obesity-associated hypertension. Elevated level of leptin in obesity-associated hypertension causes an increase in the production of aldosterone, which also results in elevation of arterial blood pressure. Hyperleptinemia is associated with the progress of the atherosclerosis through secretion of pro-inflammatory cytokines, like interleukin 6 (IL-6), tumor necrosis factor α (TNF-α), IL-17, and other cytokines to promote inflammation. The release of those cytokines leads to chronic inflammatory disorders and obesity-associated MetS. Thus, the aberrant leptin level in both MetS and chronic inflammatory disorders also leads to the complication of cardiovascular diseases (CVD). Therapeutic target of leptin regarding its pro-inflammatory effect and dysregulated sympathetic nervous system activity may prevent further cardiovascular complication. This review mainly assesses the mechanism of leptin on the pathogenesis and further cardiovascular risk complication of chronic inflammatory disorders.
Collapse
Affiliation(s)
- Gashaw Dessie
- Department of Biochemistry, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
- Correspondence: Gashaw Dessie Tel +251 975152796 Email
| | - Birhanu Ayelign
- Department of Immunology and Molecular Biology, School of Biomedical and Laboratory Science, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Yonas Akalu
- Department of Physiology, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Tewodros Shibabaw
- Department of Biochemistry, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Meseret Derbew Molla
- Department of Biochemistry, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| |
Collapse
|
17
|
Charoenwoodhipong P, Harlow SD, Marder W, Hassett AL, McCune WJ, Gordon C, Helmick CG, Barbour KE, Wang L, Mancuso P, Somers EC, Zick SM. Dietary Omega Polyunsaturated Fatty Acid Intake and Patient-Reported Outcomes in Systemic Lupus Erythematosus: The Michigan Lupus Epidemiology and Surveillance Program. Arthritis Care Res (Hoboken) 2020; 72:874-881. [PMID: 31074595 PMCID: PMC6842394 DOI: 10.1002/acr.23925] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 05/07/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To examine associations between dietary intake of omega-3 (n-3; generally antiinflammatory) and omega-6 (n-6; generally proinflammatory) fatty acids and patient-reported outcomes in systemic lupus erythematosus (SLE). METHODS This study was based on the population-based Michigan Lupus Epidemiology and Surveillance cohort. Estimates of n-3 and n-6 intake were derived from Diet History Questionnaire II items (past year with portion size version). Patient-reported outcomes included self-reported lupus activity (Systemic Lupus Activity Questionnaire [SLAQ]). Multivariable regression, adjusted for age, sex, race, and body mass index, was used to assess associations between absolute intake of n-3 and n-6, as well as the n-6:n-3 ratio, and patient-reported outcomes. RESULTS Among 456 SLE cases, 425 (93.2%) were female, 207 (45.4%) were African American, and the mean ± SD age was 52.9 ± 12.3 years. Controlling for potential confounders, the average SLAQ score was significantly higher by 0.3 points (95% confidence interval [95% CI] 0.1, 0.6; P = 0.013) with each unit increase of the n-6:n-3 ratio. Both lupus activity and Patient-Reported Outcomes Measurement Information System (PROMIS) sleep disturbance scores were lower with each 1-gram/1,000 kcal increase of n-3 fatty acids (SLAQ regression coefficient β = -0.8 [95% CI -1.6, 0.0]; P = 0.055; PROMIS sleep β = -1.1 [95% CI -2.0, -0.2]; P = 0.017). Higher n-3 intakes were nonsignificantly associated with lower levels of depressive symptoms and comorbid fibromyalgia, and with higher quality of life, whereas results for the n6:n3 ratio trended in the opposite direction. CONCLUSION This population-based study suggests that higher dietary intake of n-3 fatty acids and lower n-6:n-3 ratios are favorably associated with patient-reported outcomes in SLE, particularly self-reported lupus activity and sleep quality.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | - Lu Wang
- University of MichiganAnn Arbor
| | | | | | | |
Collapse
|
18
|
Wierenga KA, Strakovsky RS, Benninghoff AD, Rajasinghe LD, Lock AL, Harkema JR, Pestka JJ. Requisite Omega-3 HUFA Biomarker Thresholds for Preventing Murine Lupus Flaring. Front Immunol 2020; 11:1796. [PMID: 32973753 PMCID: PMC7473030 DOI: 10.3389/fimmu.2020.01796] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 07/06/2020] [Indexed: 12/28/2022] Open
Abstract
Lupus is a systemic autoimmune disease typified by uncontrolled inflammation, disruption of immune tolerance, and intermittent flaring - events triggerable by environmental factors. Preclinical and clinical studies reveal that consumption of the marine ω-3 highly unsaturated fatty acids (HUFAs) eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) might be used as a precision nutrition intervention to lessen lupus symptoms. The anti-inflammatory and pro-resolving effects of ω-3 HUFAs are inextricably linked to their presence in membrane phospholipids. The ω-3 HUFA score, calculated as [100 × (ω-3 HUFAs/(ω-3 HUFAs + ω-6 HUFAs))] in red blood cells (RBCs), and the Omega-3 Index (O3I), calculated as [100 × ((DHA+EPA)/total fatty acids)] in RBCs, are two biomarkers potentially amenable to relating tissue HUFA balance to clinical outcomes in individuals with lupus. Using data from three prior preclinical DHA supplementation studies, we tested the hypothesis that the ω-3 HUFA score and the O3I inversely correlate with indicators of autoimmune pathogenesis in the cSiO2-triggered lupus flaring model. The three studies employed both low and high fat rodent diets, as well as more complex diets emulating the U.S. dietary pattern. The ω-3 HUFA scores in RBCs were comparatively more robust than the O3I at predicting HUFA balances in the kidney, liver, spleen, and lung. Importantly, increases in both the ω-3 HUFA score (>40%) and the O3I (>10%) were strongly associated with suppression of cSiO2-triggered (1) expression of interferon-regulated genes, proinflammatory cytokine production, leukocyte infiltration, and ectopic lymphoid structure development in the lung, (2) pulmonary and systemic autoantibody production, and (3) glomerulonephritis. Collectively, these findings identify achievable ω-3 HUFA scores and O3I thresholds that could be targeted in future human intervention studies querying how ω-3 HUFA consumption influences lupus and other autoimmune diseases.
Collapse
MESH Headings
- Animal Feed
- Animals
- Autoimmunity
- Biomarkers/blood
- Bronchoalveolar Lavage Fluid/immunology
- Cytokines/metabolism
- Diet
- Disease Models, Animal
- Erythrocytes/metabolism
- Fatty Acids, Omega-3/administration & dosage
- Fatty Acids, Omega-3/blood
- Fatty Acids, Omega-6/administration & dosage
- Fatty Acids, Omega-6/blood
- Female
- Inflammation Mediators/metabolism
- Lupus Erythematosus, Systemic/blood
- Lupus Erythematosus, Systemic/diagnosis
- Lupus Erythematosus, Systemic/diet therapy
- Lupus Erythematosus, Systemic/immunology
- Mice, Inbred NZB
- Predictive Value of Tests
- Symptom Flare Up
Collapse
Affiliation(s)
- Kathryn A. Wierenga
- Department of Biochemistry and Molecular Biology, Michigan State University, East Lansing, MI, United States
- Institute for Integrative Toxicology, Michigan State University, East Lansing, MI, United States
| | - Rita S. Strakovsky
- Institute for Integrative Toxicology, Michigan State University, East Lansing, MI, United States
- Department of Food Science and Human Nutrition, Michigan State University, East Lansing, MI, United States
| | - Abby D. Benninghoff
- Department of Animal, Dairy and Veterinary Sciences and USTAR Applied Nutrition Research, Utah State University, Logan, UT, United States
| | - Lichchavi D. Rajasinghe
- Institute for Integrative Toxicology, Michigan State University, East Lansing, MI, United States
- Department of Food Science and Human Nutrition, Michigan State University, East Lansing, MI, United States
| | - Adam L. Lock
- Department of Animal Science, Michigan State University, East Lansing, MI, United States
| | - Jack R. Harkema
- Institute for Integrative Toxicology, Michigan State University, East Lansing, MI, United States
- Department of Pathobiology and Diagnostic Investigation, Michigan State University, East Lansing, MI, United States
| | - James J. Pestka
- Institute for Integrative Toxicology, Michigan State University, East Lansing, MI, United States
- Department of Food Science and Human Nutrition, Michigan State University, East Lansing, MI, United States
- Department of Microbiology and Molecular Genetics, Michigan State University, East Lansing, MI, United States
| |
Collapse
|
19
|
Gilley KN, Wierenga KA, Chauhuan PS, Wagner JG, Lewandowski RP, Ross EA, Lock AL, Harkema JR, Benninghoff AD, Pestka JJ. Influence of total western diet on docosahexaenoic acid suppression of silica-triggered lupus flaring in NZBWF1 mice. PLoS One 2020; 15:e0233183. [PMID: 32413078 PMCID: PMC7228097 DOI: 10.1371/journal.pone.0233183] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 04/29/2020] [Indexed: 12/13/2022] Open
Abstract
Lupus is a debilitating multi-organ autoimmune disease clinically typified by periods of flare and remission. Exposing lupus-prone female NZBWF1 mice to crystalline silica (cSiO2), a known human autoimmune trigger, mimics flaring by inducing interferon-related gene (IRG) expression, inflammation, ectopic lymphoid structure (ELS) development, and autoantibody production in the lung that collectively accelerate glomerulonephritis. cSiO2-triggered flaring in this model can be prevented by supplementing mouse diet with the ω-3 polyunsaturated fatty acid (PUFA) docosahexaenoic acid (DHA). A limitation of previous studies was the use of purified diet that, although optimized for rodent health, does not reflect the high American intake of saturated fatty acid (SFA), ω-6 PUFAs, and total fat. To address this, we employed here a modified Total Western Diet (mTWD) emulating the 50th percentile U.S. macronutrient distribution to discern how DHA supplementation and/or SFA and ω-6 reduction influences cSiO2-triggered lupus flaring in female NZBWF1 mice. Six-week-old mice were fed isocaloric experimental diets for 2 wks, intranasally instilled with cSiO2 or saline vehicle weekly for 4 wks, and tissues assessed for lupus endpoints 11 wks following cSiO2 instillation. In mice fed basal mTWD, cSiO2 induced robust IRG expression, proinflammatory cytokine and chemokine elevation, leukocyte infiltration, ELS neogenesis, and autoantibody production in the lung, as well as early kidney nephritis onset compared to vehicle-treated mice fed mTWD. Consumption of mTWD containing DHA at the caloric equivalent to a human dose of 5 g/day dramatically suppressed induction of all lupus-associated endpoints. While decreasing SFA and ω-6 in mTWD modestly inhibited some disease markers, DHA addition to this diet was required for maximal protection against lupus development. Taken together, DHA supplementation at a translationally relevant dose was highly effective in preventing cSiO2-triggered lupus flaring in NZBWF1 mice, even against the background of a typical Western diet.
Collapse
Affiliation(s)
- Kristen N. Gilley
- Department of Food Science and Human Nutrition, Michigan State University, East Lansing, Michigan, United States of America
| | - Kathryn A. Wierenga
- Department of Biochemistry and Molecular Biology, Michigan State University, East Lansing, Michigan, United States of America
- Institute for Integrative Toxicology, Michigan State University, East Lansing, Michigan, United States of America
| | - Preeti S. Chauhuan
- Department of Food Science and Human Nutrition, Michigan State University, East Lansing, Michigan, United States of America
- Department of Biochemistry and Molecular Biology, Michigan State University, East Lansing, Michigan, United States of America
| | - James G. Wagner
- Institute for Integrative Toxicology, Michigan State University, East Lansing, Michigan, United States of America
- Department of Pathobiology and Diagnostic Investigation, Michigan State University, East Lansing, Michigan, United States of America
| | - Ryan P. Lewandowski
- Department of Pathobiology and Diagnostic Investigation, Michigan State University, East Lansing, Michigan, United States of America
| | - Elizbeth A. Ross
- Department of Food Science and Human Nutrition, Michigan State University, East Lansing, Michigan, United States of America
| | - A. L. Lock
- Department of Animal Science, Michigan State University, East Lansing, Michigan, United States of America
| | - Jack R. Harkema
- Institute for Integrative Toxicology, Michigan State University, East Lansing, Michigan, United States of America
- Department of Pathobiology and Diagnostic Investigation, Michigan State University, East Lansing, Michigan, United States of America
| | - Abby D. Benninghoff
- Department of Animal, Dairy and Veterinary Sciences, School of Veterinary Medicine, Utah State University, Logan, Utah, United States of America
| | - James J. Pestka
- Department of Food Science and Human Nutrition, Michigan State University, East Lansing, Michigan, United States of America
- Institute for Integrative Toxicology, Michigan State University, East Lansing, Michigan, United States of America
- Department of Microbiology and Molecular Genetics, East Lansing, Michigan, United States of America
| |
Collapse
|
20
|
Benninghoff AD, Bates MA, Chauhan PS, Wierenga KA, Gilley KN, Holian A, Harkema JR, Pestka JJ. Docosahexaenoic Acid Consumption Impedes Early Interferon- and Chemokine-Related Gene Expression While Suppressing Silica-Triggered Flaring of Murine Lupus. Front Immunol 2019; 10:2851. [PMID: 31921124 PMCID: PMC6923248 DOI: 10.3389/fimmu.2019.02851] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Accepted: 11/20/2019] [Indexed: 12/18/2022] Open
Abstract
Exposure of lupus-prone female NZBWF1 mice to respirable crystalline silica (cSiO2), a known human autoimmune trigger, initiates loss of tolerance, rapid progression of autoimmunity, and early onset of glomerulonephritis. We have previously demonstrated that dietary supplementation with the ω-3 polyunsaturated fatty acid docosahexaenoic acid (DHA) suppresses autoimmune pathogenesis and nephritis in this unique model of lupus flaring. In this report, we utilized tissues from prior studies to test the hypothesis that DHA consumption interferes with upregulation of critical genes associated with cSiO2-triggered murine lupus. A NanoString nCounter platform targeting 770 immune-related genes was used to assess the effects cSiO2 on mRNA signatures over time in female NZBWF1 mice consuming control (CON) diets compared to mice fed diets containing DHA at an amount calorically equivalent to human consumption of 2 g per day (DHA low) or 5 g per day (DHA high). Experimental groups of mice were sacrificed: (1) 1 d after a single intranasal instillation of 1 mg cSiO2 or vehicle, (2) 1 d after four weekly single instillations of vehicle or 1 mg cSiO2, and (3) 1, 5, 9, and 13 weeks after four weekly single instillations of vehicle or 1 mg cSiO2. Genes associated with inflammation as well as innate and adaptive immunity were markedly upregulated in lungs of CON-fed mice 1 d after four weekly cSiO2 doses but were significantly suppressed in mice fed DHA high diets. Importantly, mRNA signatures in lungs of cSiO2-treated CON-fed mice over 13 weeks reflected progressive amplification of interferon (IFN)- and chemokine-related gene pathways. While these responses in the DHA low group were suppressed primarily at week 5, significant downregulation was observed at weeks 1, 5, 9, and 13 in mice fed the DHA high diet. At week 13, cSiO2 treatment of CON-fed mice affected 214 genes in kidney tissue associated with inflammation, innate/adaptive immunity, IFN, chemokines, and antigen processing, mostly by upregulation; however, feeding DHA dose-dependently suppressed these responses. Taken together, dietary DHA intake in lupus-prone mice impeded cSiO2-triggered mRNA signatures known to be involved in ectopic lymphoid tissue neogenesis, systemic autoimmunity, and glomerulonephritis.
Collapse
Affiliation(s)
- Abby D. Benninghoff
- Department of Animal, Dairy and Veterinary Sciences and The School of Veterinary Medicine, Utah State University, Logan, UT, United States
| | - Melissa A. Bates
- Department of Food Science and Human Nutrition, Michigan State University, East Lansing, MI, United States
- Institute for Integrative Toxicology, Michigan State University, East Lansing, MI, United States
| | - Preeti S. Chauhan
- Department of Food Science and Human Nutrition, Michigan State University, East Lansing, MI, United States
| | - Kathryn A. Wierenga
- Institute for Integrative Toxicology, Michigan State University, East Lansing, MI, United States
- Department of Biochemistry and Molecular Biology, Michigan State University, East Lansing, MI, United States
| | - Kristen N. Gilley
- Department of Food Science and Human Nutrition, Michigan State University, East Lansing, MI, United States
| | - Andrij Holian
- Department of Biomedical and Pharmaceutical Sciences, Center for Environmental Health Sciences, University of Montana, Missoula, MT, United States
| | - Jack R. Harkema
- Institute for Integrative Toxicology, Michigan State University, East Lansing, MI, United States
- Department of Pathobiology and Diagnostic Investigation, Michigan State University, East Lansing, MI, United States
| | - James J. Pestka
- Department of Food Science and Human Nutrition, Michigan State University, East Lansing, MI, United States
- Institute for Integrative Toxicology, Michigan State University, East Lansing, MI, United States
- Department of Microbiology and Molecular Genetics, Michigan State University, East Lansing, MI, United States
| |
Collapse
|
21
|
Role of the Specialized Proresolving Mediator Resolvin D1 in Systemic Lupus Erythematosus: Preliminary Results. J Immunol Res 2018; 2018:5264195. [PMID: 30420970 PMCID: PMC6215556 DOI: 10.1155/2018/5264195] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 09/20/2018] [Indexed: 01/09/2023] Open
Abstract
Objective Systemic lupus erythematosus (SLE) is an autoimmune systemic disease and its pathogenesis has not yet been completely clarified. Patients with SLE show a deranged lipid metabolism, which can contribute to the immunopathogenesis of the disease and to the accelerated atherosclerosis. Resolvin D1 (RvD1), a product of the metabolism of the omega-3 polyunsaturated fatty acid docosahexaenoic acid (DHA), acts as a specialized proresolving mediator which can contribute in restoring the homeostasis in inflamed tissues. The aim of the present pilot study is to evaluate plasma levels of RvD1 in patients with SLE and healthy subjects, investigating its potential role as a biomarker of SLE and assessing its relationship with disease activity and laboratory parameters. Methods Thirty patients with SLE and thirty age- and sex-matched healthy subjects (HSs) have been consecutively recruited at Campus Bio-Medico University Hospital. RvD1 plasma levels were measured by ELISA according to the manufacturer's protocol (Cayman Chemical Co.). RvD1 levels were compared using Mann-Whitney test. Discriminatory ability for SLE has been evaluated by the area under the ROC curve. Results Lower levels of RvD1, 45.6 (35.5-57.4) pg/ml, in patients with SLE have been found compared to HSs, 65.1 (39.43-87.95) pg/ml (p = 0.0043). The area under the ROC curve (AUC) for RvD1 was 0.71 (95% CI: 0.578-0.82) and the threshold value of RvD1 for the classification of SLE was <58.4 pg/ml, sensitivity 80% (95% CI: 61.4-92.3), and specificity 63.3% (95% CI: 43.9-80.1), likelihood ratio 2.2 (95% CI: 1.3-3.6). Conclusions The present preliminary study allows hypothesizing a dysregulation of RvD1 in patients with SLE, confirming the emerging role of bioactive lipids in this disease.
Collapse
|
22
|
Navarini L, Margiotta DPE, Vadacca M, Afeltra A. Leptin in autoimmune mechanisms of systemic rheumatic diseases. Cancer Lett 2018; 423:139-146. [PMID: 29548819 DOI: 10.1016/j.canlet.2018.03.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 03/08/2018] [Accepted: 03/08/2018] [Indexed: 12/28/2022]
Abstract
In the last two decades, white adipose tissue (WAT) has been recognized as a key actor of many physiological and pathological conditions. WAT is able to produce mediators, named "adipokines", which may affect systemic homeostasis. In particular, leptin is not only involved in appetite and energy metabolism, but also in immune system. Increasing evidence established that leptin can regulate both innate and adaptive immunity mainly with pro-inflammatory effects but also, to a lesser extent, with anti-inflammatory features. In autoimmune diseases, a failure or breakdown of the mechanisms of self-tolerance is observed. Leptin, which plays an important role in the control of immune balance, has been involved in autoimmunity generation and maintenance. In this review, it has been provided an up-to-date report about the role of leptin in systemic autoimmune diseases, with particular reference to connective tissue diseases, inflammatory arthritis, and vasculitis.
Collapse
Affiliation(s)
- Luca Navarini
- Unit of Allergology, Immunology, Rheumatology, Department of Medicine, Università Campus Bio-Medico di Roma, Via Álvaro del Portillo 21, 00128 Rome, Italy
| | - Domenico Paolo Emanuele Margiotta
- Unit of Allergology, Immunology, Rheumatology, Department of Medicine, Università Campus Bio-Medico di Roma, Via Álvaro del Portillo 21, 00128 Rome, Italy.
| | - Marta Vadacca
- Unit of Allergology, Immunology, Rheumatology, Department of Medicine, Università Campus Bio-Medico di Roma, Via Álvaro del Portillo 21, 00128 Rome, Italy
| | - Antonella Afeltra
- Unit of Allergology, Immunology, Rheumatology, Department of Medicine, Università Campus Bio-Medico di Roma, Via Álvaro del Portillo 21, 00128 Rome, Italy
| |
Collapse
|
23
|
|
24
|
Abstract
AbstractSystemic lupus erythematosus (SLE) is a chronic inflammatory and autoimmune disease characterised by multiple organ involvement and a large number of complications. SLE management remains complicated owing to the biological heterogeneity between patients and the lack of safe and specific targeted therapies. There is evidence that dietary factors can contribute to the geoepidemiology of autoimmune diseases such as SLE. Thus, diet therapy could be a promising approach in SLE owing to both its potential prophylactic effects, without the side effects of classical pharmacology, and its contribution to reducing co-morbidities and improving quality of life in patients with SLE. However, the question arises as to whether nutrients could ameliorate or exacerbate SLE and how they could modulate inflammation and immune function at a molecular level. The present review summarises preclinical and clinical experiences to provide the reader with an update of the positive and negative aspects of macro- and micronutrients and other nutritional factors, including dietary phenols, on SLE, focusing on the mechanisms of action involved.
Collapse
|
25
|
Mu Q, Zhang H, Luo XM. SLE: Another Autoimmune Disorder Influenced by Microbes and Diet? Front Immunol 2015; 6:608. [PMID: 26648937 PMCID: PMC4663251 DOI: 10.3389/fimmu.2015.00608] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Accepted: 11/16/2015] [Indexed: 12/20/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a multi-system autoimmune disease. Despite years of study, the etiology of SLE is still unclear. Both genetic and environmental factors have been implicated in the disease mechanisms. In the past decade, a growing body of evidence has indicated an important role of gut microbes in the development of autoimmune diseases, including type 1 diabetes, rheumatoid arthritis, and multiple sclerosis. However, such knowledge on SLE is little, though we have already known that environmental factors can trigger the development of lupus. Several recent studies have suggested that alterations of the gut microbial composition may be correlated with SLE disease manifestations, while the exact roles of either symbiotic or pathogenic microbes in this disease remain to be explored. Elucidation of the roles of gut microbes - as well as the roles of diet that can modulate the composition of gut microbes - in SLE will shed light on how this autoimmune disorder develops, and provide opportunities for improved biomarkers of the disease and the potential to probe new therapies. In this review, we aim to compile the available evidence on the contributions of diet and gut microbes to SLE occurrence and pathogenesis.
Collapse
Affiliation(s)
- Qinghui Mu
- Department of Biomedical Sciences and Pathobiology, Virginia Tech , Blacksburg, VA , USA
| | - Husen Zhang
- Department of Civil and Environmental Engineering, Virginia Tech , Blacksburg, VA , USA
| | - Xin M Luo
- Department of Biomedical Sciences and Pathobiology, Virginia Tech , Blacksburg, VA , USA
| |
Collapse
|