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Holmboe SA, Beck AL, Andersson AM, Main KM, Jørgensen N, Skakkebæk NE, Priskorn L. The epidemiology of cryptorchidism and potential risk factors, including endocrine disrupting chemicals. Front Endocrinol (Lausanne) 2024; 15:1343887. [PMID: 38633762 PMCID: PMC11021654 DOI: 10.3389/fendo.2024.1343887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 03/22/2024] [Indexed: 04/19/2024] Open
Abstract
Congenital cryptorchidism, also known as undescended testis, is the condition where one or both testes are not in place in the scrotum at birth and is one of the most common birth defects in boys. Temporal trends and geographic variation in the prevalence of cryptorchidism from 1% to 9% have been reported in prospective cohort studies. The testes develop in the abdominal cavity and descend to the scrotum in two phases, which should be completed by gestational week 35. Thus, the risk of cryptorchidism is higher in preterm boys. In many cases a spontaneous descent occurs during the first months of life during the surge of gonadotropins and testosterone. If not, the testis is usually brought down to the scrotum, typically by surgery, to increase future fertility chances and facilitate cancer surveillance. The increasing frequency of impaired semen quality and testicular cancer, with which cryptorchidism is associated, represents a concern for male reproductive health in general and a need to understand its risk factors. The risk of cryptorchidism is closely related to gestational factors (preterm birth, low birth weight and intrauterine growth restriction), and especially maternal smoking seems to be a risk factor. Evidence is accumulating that the increasing prevalence of cryptorchidism is also related to prenatal exposure to environmental chemicals, including endocrine disrupting compounds. This association has been corroborated in rodents and supported by ecological studies. Conducting human studies to assess the effect of endocrine disrupting chemicals and their interactions is, however, challenged by the widespread concomitant exposure of all humans to a wide range of chemicals, the combined effect of which and their interactions are highly complex.
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Affiliation(s)
- Stine A. Holmboe
- Department of Growth and Reproduction, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Astrid L. Beck
- Department of Growth and Reproduction, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Anna-Maria Andersson
- Department of Growth and Reproduction, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Katharina M. Main
- Department of Growth and Reproduction, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Niels Jørgensen
- Department of Growth and Reproduction, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Niels E. Skakkebæk
- Department of Growth and Reproduction, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Lærke Priskorn
- Department of Growth and Reproduction, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- International Center for Research and Research Training in Endocrine Disruption of Male Reproduction and Child Health (EDMaRC), Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
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Lou Y, Lin C, Yang T, Sun Z, Lei L, Song Y, Huang C, Chen J. DDT exposure induces tremor-like behavior and neurotoxicity in developmental stages of embryonic zebrafish. ECOTOXICOLOGY AND ENVIRONMENTAL SAFETY 2024; 271:116001. [PMID: 38277973 DOI: 10.1016/j.ecoenv.2024.116001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 01/13/2024] [Accepted: 01/18/2024] [Indexed: 01/28/2024]
Abstract
Dichlorodiphenyltrichloroethane (DDT) is a broad-spectrum insecticide, widely detected in environments due to its high stability characteristic and long natural half-life period. The adverse impact of DDT exposure on organisms and humans has attracted great concern worldwide. The current study explored the developmental and neurobehavioral toxicity response of DDT in embryonic zebrafish. The embryos were treated with DDT (0, 0.1, 1, 2.5 and 5 µM) during 6 h post fertilization (hpf) to 144 hpf. Our result indicated that DDT exposures increased the embryo hatching rate at 48 and 60 hpf, the larval malformation rate at 120 hpf and mortality rate at 144 hpf. The manifested malformations included uninflated swim bladder, bent spine and tail, deformed liver, and pericardial edema. The 120 hpf larval organs size of the gut and swim bladder was decreased in higher exposed concentration groups. Besides, DDT exposure resulted in hyperactivity for the embryo spontaneous movement at 24 hpf and tremor like movement measured by the free larval activity at 72 hpf, as well as the larval activity at 96 hpf under light-dark transition stimulus. Mechanistic examinations at 120 hpf revealed DDT exposure elevated oxidative stress through MDA formation increase, ATP level decrease as well as antioxidant enzyme genes (sod1 and gpx1a) expression decrease. DDT exposure induced abnormal neurotransmitters expression with DA level increase, 5-HT and NOS level decrease. DDT exposure suppressed the gene expressions involved in axon development (rab33a and nrxn2a) and potassium channel (kcnq2 and kcnq3). Our results suggest that the hyperactivity and tremor like movement in DDT-exposed embryos/larvae may result from oxidative stress involved with neuronal damage.
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Affiliation(s)
- Yanqi Lou
- Wenzhou Medical University, Wenzhou 325035, PR China
| | - Chengyin Lin
- Wenzhou Medical University, Wenzhou 325035, PR China
| | - Tianpeng Yang
- Wenzhou Medical University, Wenzhou 325035, PR China; Zhejiang Provincial Key Laboratory of Watershed Sciences and Health, School of Public health, Wenzhou Medical University, Wenzhou 325035, PR China
| | - Zhenkai Sun
- Wenzhou Medical University, Wenzhou 325035, PR China; Wenzhou Municipal Key Laboratory of Neurodevelopmental Pathology and Physiology, Wenzhou Medical University, Wenzhou, 325035, PR China
| | - Lei Lei
- Wenzhou Medical University, Wenzhou 325035, PR China; Zhejiang Provincial Key Laboratory of Watershed Sciences and Health, School of Public health, Wenzhou Medical University, Wenzhou 325035, PR China
| | - Yang Song
- State Key Laboratory of Environmental Chemistry and Ecotoxicology, Research Center for Eco-Environmental Sciences, Chinese Academy of Sciences, Beijing 100085, PR China
| | - Changjiang Huang
- Wenzhou Medical University, Wenzhou 325035, PR China; Zhejiang Provincial Key Laboratory of Watershed Sciences and Health, School of Public health, Wenzhou Medical University, Wenzhou 325035, PR China.
| | - Jiangfei Chen
- Wenzhou Medical University, Wenzhou 325035, PR China; Zhejiang Provincial Key Laboratory of Watershed Sciences and Health, School of Public health, Wenzhou Medical University, Wenzhou 325035, PR China; Wenzhou Municipal Key Laboratory of Neurodevelopmental Pathology and Physiology, Wenzhou Medical University, Wenzhou, 325035, PR China; State Key Laboratory of Environmental Chemistry and Ecotoxicology, Research Center for Eco-Environmental Sciences, Chinese Academy of Sciences, Beijing 100085, PR China.
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Arab A, Mostafalou S. Pesticides and insulin resistance-related metabolic diseases: Evidences and mechanisms. PESTICIDE BIOCHEMISTRY AND PHYSIOLOGY 2023; 195:105521. [PMID: 37666627 DOI: 10.1016/j.pestbp.2023.105521] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 07/01/2023] [Accepted: 07/05/2023] [Indexed: 09/06/2023]
Abstract
The use of pesticides in the past century has lot helped humankind in improving crops' field and general hygiene level. Nevertheless, there has been countless evidences on the toxic effects of pesticides on the living systems. The link of exposure to pesticides with different human chronic diseases in the context of carcinogenicity, neurotoxicity, developmental toxicity, etc., have been evaluated in various types of studies. There are also some evidences on the link of exposure to pesticides with higher incidence of metabolic diseases associated with insulin resistance like diabetes, obesity, metabolic syndrome, hypertension, polycystic ovary syndrome and chronic kidney diseases. Physiologically, weakening intracellular insulin signaling is considered as a compensatory mechanism for cells to cope with cellular stresses like xenobiotic effects, oxidative stress and inflammatory responses, but it can pathologically lead to a defective cycle with lowered sensitivity of the cells to insulin which happens in metabolic disorders. In this work, the data related to metabolic toxicity of pesticides categorized in the mentioned metabolic diseases with a focus on the effects of pesticides on insulin signaling pathway and the mechanisms of development of insulin resistance will be systematically reviewed and presented.
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Affiliation(s)
- Ali Arab
- Department of Pharmacology and Toxicology, School of Pharmacy, Ardabil University of Medical Sciences, Ardabil, Iran
| | - Sara Mostafalou
- Department of Pharmacology and Toxicology, School of Pharmacy, Ardabil University of Medical Sciences, Ardabil, Iran.
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Núñez-Sánchez MÁ, Jiménez-Méndez A, Suárez-Cortés M, Martínez-Sánchez MA, Sánchez-Solís M, Blanco-Carnero JE, Ruiz-Alcaraz AJ, Ramos-Molina B. Inherited Epigenetic Hallmarks of Childhood Obesity Derived from Prenatal Exposure to Obesogens. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:ijerph20064711. [PMID: 36981620 PMCID: PMC10048338 DOI: 10.3390/ijerph20064711] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/04/2023] [Accepted: 03/06/2023] [Indexed: 06/01/2023]
Abstract
Childhood obesity has reached epidemic levels in developed countries and is becoming a major cause for concern in the developing world. The causes of childhood obesity are complex and multifactorial, involving the interaction between individual genetics and environmental and developmental factors. Among the environmental factors, there is a growing interest in understanding the possible relationship between the so-called environmental obesogens and the development of obesity in children. Exposure to these obesogens such as phthalates, bisphenol A, or parabens, has been identified as a promoter of obesity through different mechanisms such as the alteration of adipocyte development from mesenchymal progenitors, the interference with hormone receptors, and induced inflammation. However, less attention has been paid to the inheritance of epigenetic modifications due to maternal exposure to these compounds during pregnancy. Thus, the aim of this review is to summarize the current knowledge of epigenetic modifications due to maternal exposure to those obesogens during pregnancy as well as their potential implication on long-term obesity development in the offspring and transgenerational inheritance of epiphenotypes.
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Affiliation(s)
- María Á Núñez-Sánchez
- Obesity and Metabolism Research Laboratory, Biomedical Research Institute of Murcia (IMIB), 30120 Murcia, Spain
| | - Almudena Jiménez-Méndez
- Department of Obstetrics and Gynecology, 'Virgen de la Arrixaca' University Clinical Hospital, 30120 Murcia, Spain
| | - María Suárez-Cortés
- Department of Nursing, Faculty of Nursing, University of Murcia, El Palmar, 30120 Murcia, Spain
| | - María A Martínez-Sánchez
- Obesity and Metabolism Research Laboratory, Biomedical Research Institute of Murcia (IMIB), 30120 Murcia, Spain
| | - Manuel Sánchez-Solís
- Group of Pediatric Research, Biomedical Research Institute of Murcia (IMIB), 30120 Murcia, Spain
- Respiratory and Allergy Units, Arrixaca Children's University Hospital, University of Murcia, 30120 Murcia, Spain
| | - José E Blanco-Carnero
- Department of Obstetrics and Gynecology, 'Virgen de la Arrixaca' University Clinical Hospital, 30120 Murcia, Spain
- Gynecology, Reproduction and Maternal-Fetal Medicine Research Group, Biomedical Research Institute of Murcia (IMIB), 30120 Murcia, Spain
| | - Antonio J Ruiz-Alcaraz
- Department of Biochemistry, Molecular Biology B and Immunology, School of Medicine, University of Murcia, Regional Campus of International Excellence "Campus Mare Nostrum", 30100 Murcia, Spain
| | - Bruno Ramos-Molina
- Obesity and Metabolism Research Laboratory, Biomedical Research Institute of Murcia (IMIB), 30120 Murcia, Spain
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Miranda RA, Silva BS, de Moura EG, Lisboa PC. Pesticides as endocrine disruptors: programming for obesity and diabetes. Endocrine 2023; 79:437-447. [PMID: 36301509 DOI: 10.1007/s12020-022-03229-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 07/28/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Exposure to pesticides has been associated with obesity and diabetes in humans and experimental models mainly due to endocrine disruptor effects. First contact with environmental pesticides occurs during critical phases of life, such as gestation and lactation, which can lead to damage in central and peripheral tissues and subsequently programming disorders early and later in life. METHODS We reviewed epidemiological and experimental studies that associated pesticide exposure during gestation and lactation with programming obesity and diabetes in progeny. RESULTS Maternal exposure to organochlorine, organophosphate and neonicotinoids, which represent important pesticide groups, is related to reproductive and behavioral dysfunctions in offspring; however, few studies have focused on glucose metabolism and obesity as outcomes. CONCLUSION We provide an update regarding the use and metabolic impact of early pesticide exposure. Considering their bioaccumulation in soil, water, and food and through the food chain, pesticides should be considered a great risk factor for several diseases. Thus, it is urgent to reformulate regulatory actions to reduce the impact of pesticides on the health of future generations.
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Affiliation(s)
- Rosiane Aparecida Miranda
- Laboratory of Endocrine Physiology, Biology Institute, Rio de Janeiro State University, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Beatriz Souza Silva
- Laboratory of Endocrine Physiology, Biology Institute, Rio de Janeiro State University, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Egberto Gaspar de Moura
- Laboratory of Endocrine Physiology, Biology Institute, Rio de Janeiro State University, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Patrícia Cristina Lisboa
- Laboratory of Endocrine Physiology, Biology Institute, Rio de Janeiro State University, Rio de Janeiro, Rio de Janeiro, Brazil.
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Kowalczyk M, Piwowarski JP, Wardaszka A, Średnicka P, Wójcicki M, Juszczuk-Kubiak E. Application of In Vitro Models for Studying the Mechanisms Underlying the Obesogenic Action of Endocrine-Disrupting Chemicals (EDCs) as Food Contaminants-A Review. Int J Mol Sci 2023; 24:ijms24021083. [PMID: 36674599 PMCID: PMC9866663 DOI: 10.3390/ijms24021083] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 12/29/2022] [Accepted: 01/04/2023] [Indexed: 01/09/2023] Open
Abstract
Obesogenic endocrine-disrupting chemicals (EDCs) belong to the group of environmental contaminants, which can adversely affect human health. A growing body of evidence supports that chronic exposure to EDCs can contribute to a rapid increase in obesity among adults and children, especially in wealthy industrialized countries with a high production of widely used industrial chemicals such as plasticizers (bisphenols and phthalates), parabens, flame retardants, and pesticides. The main source of human exposure to obesogenic EDCs is through diet, particularly with the consumption of contaminated food such as meat, fish, fruit, vegetables, milk, and dairy products. EDCs can promote obesity by stimulating adipo- and lipogenesis of target cells such as adipocytes and hepatocytes, disrupting glucose metabolism and insulin secretion, and impacting hormonal appetite/satiety regulation. In vitro models still play an essential role in investigating potential environmental obesogens. The review aimed to provide information on currently available two-dimensional (2D) in vitro animal and human cell models applied for studying the mechanisms of obesogenic action of various industrial chemicals such as food contaminants. The advantages and limitations of in vitro models representing the crucial endocrine tissue (adipose tissue) and organs (liver and pancreas) involved in the etiology of obesity and metabolic diseases, which are applied to evaluate the effects of obesogenic EDCs and their disruption activity, were thoroughly and critically discussed.
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Affiliation(s)
- Monika Kowalczyk
- Laboratory of Biotechnology and Molecular Engineering, Department of Microbiology, Prof. Wacław Dąbrowski Institute of Agricultural and Food Biotechnology—State Research Institute, 02-532 Warsaw, Poland
| | - Jakub P. Piwowarski
- Microbiota Lab, Department of Pharmacognosy and Molecular Basis of Phytotherapy, Medical University of Warsaw, 02-097 Warsaw, Poland
- Correspondence: (J.P.P.); (E.J.-K.)
| | - Artur Wardaszka
- Laboratory of Biotechnology and Molecular Engineering, Department of Microbiology, Prof. Wacław Dąbrowski Institute of Agricultural and Food Biotechnology—State Research Institute, 02-532 Warsaw, Poland
| | - Paulina Średnicka
- Laboratory of Biotechnology and Molecular Engineering, Department of Microbiology, Prof. Wacław Dąbrowski Institute of Agricultural and Food Biotechnology—State Research Institute, 02-532 Warsaw, Poland
| | - Michał Wójcicki
- Laboratory of Biotechnology and Molecular Engineering, Department of Microbiology, Prof. Wacław Dąbrowski Institute of Agricultural and Food Biotechnology—State Research Institute, 02-532 Warsaw, Poland
| | - Edyta Juszczuk-Kubiak
- Laboratory of Biotechnology and Molecular Engineering, Department of Microbiology, Prof. Wacław Dąbrowski Institute of Agricultural and Food Biotechnology—State Research Institute, 02-532 Warsaw, Poland
- Correspondence: (J.P.P.); (E.J.-K.)
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The Role of Persistent Organic Pollutants in Obesity: A Review of Laboratory and Epidemiological Studies. TOXICS 2022; 10:toxics10020065. [PMID: 35202251 PMCID: PMC8877532 DOI: 10.3390/toxics10020065] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 01/29/2022] [Accepted: 01/30/2022] [Indexed: 11/17/2022]
Abstract
Persistent organic pollutants (POPs) are considered as potential obesogens that may affect adipose tissue development and functioning, thus promoting obesity. However, various POPs may have different mechanisms of action. The objective of the present review is to discuss the key mechanisms linking exposure to POPs to adipose tissue dysfunction and obesity. Laboratory data clearly demonstrate that the mechanisms associated with the interference of exposure to POPs with obesity include: (a) dysregulation of adipogenesis regulators (PPARγ and C/EBPα); (b) affinity and binding to nuclear receptors; (c) epigenetic effects; and/or (d) proinflammatory activity. Although in vivo data are generally corroborative of the in vitro results, studies in living organisms have shown that the impact of POPs on adipogenesis is affected by biological factors such as sex, age, and period of exposure. Epidemiological data demonstrate a significant association between exposure to POPs and obesity and obesity-associated metabolic disturbances (e.g., type 2 diabetes mellitus and metabolic syndrome), although the existing data are considered insufficient. In conclusion, both laboratory and epidemiological data underline the significant role of POPs as environmental obesogens. However, further studies are required to better characterize both the mechanisms and the dose/concentration-response effects of exposure to POPs in the development of obesity and other metabolic diseases.
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Tawar N, Banerjee BD, Madhu SV, Agrawal V, Gupta S. Association of Organochlorine Pesticides With Genetic Markers of Endoplasmic Reticulum Stress in Type 2 Diabetes Mellitus: A Case-Control Study Among the North-Indian Population. Front Endocrinol (Lausanne) 2022; 13:841463. [PMID: 35370992 PMCID: PMC8966505 DOI: 10.3389/fendo.2022.841463] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 02/03/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Organochlorine pesticides (OCPs) have been long linked to type 2 diabetes mellitus (T2DM); however, this relation at the molecular level has not been explored yet. Endoplasmic reticulum (ER) stress and pro-inflammatory pathways are considered vital ones in the pathogenesis of T2DM. We aimed to investigate the existence of any association between OCPs, ER stress, and pro-inflammatory pathways in subjects with known T2DM. METHODS Seventy subjects each with T2DM and normal glucose tolerance were recruited from the surgery department. Their visceral adipose tissue was collected intraoperatively. OCP concentration, ER stress, and pro-inflammatory markers were analyzed and compared between two study groups. RESULTS We found 18 OCPs and their metabolites in visceral adipose tissue samples of study participants. The levels of δ-HCH, heptachlor, endrin, and p,p'DDT were significantly higher in the T2DM group and were also positively correlated with fasting and postprandial plasma glucose levels (p < 0.01). We observed a positive association of δ-HCH (p < 0.01), heptachlor (p < 0.05), and endrin (p < 0.05) with central adiposity and ER stress markers. However, we failed to establish the correlation of OCPs with any of the pro-inflammatory markers. CONCLUSION The existence and simultaneous complex correlation of OCPs with ER stress may explain their role in the pathogenesis of T2DM, revealing the persistence of the gene-environment interaction in the etiology of T2DM.
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Affiliation(s)
- Neha Tawar
- Department of Biochemistry, University College of Medical Sciences (UCMS) and Guru Teg Bahadur (GTB) Hospital (University of Delhi), Delhi, India
- *Correspondence: Neha Tawar, ; Basu Dev Banerjee,
| | - Basu Dev Banerjee
- Department of Biochemistry, University College of Medical Sciences (UCMS) and Guru Teg Bahadur (GTB) Hospital (University of Delhi), Delhi, India
- *Correspondence: Neha Tawar, ; Basu Dev Banerjee,
| | - Sri Venkata Madhu
- Department of Endocrinology and Metabolism, UCMS and Guru Teg Bahadur (GTB) Hospital (University of Delhi), Delhi, India
| | - Vivek Agrawal
- Department of Surgery, UCMS and Guru Teg Bahadur (GTB) Hospital (University of Delhi), Delhi, India
| | - Sanjay Gupta
- Department of Surgery, UCMS and Guru Teg Bahadur (GTB) Hospital (University of Delhi), Delhi, India
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