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Chen H, Buziau AM, Rentería ME, Simons PIHG, Brouwers MCGJ. Fructose intake from sugar-sweetened beverages is associated with a greater risk of hyperandrogenism in women: UK Biobank cohort study. Eur J Endocrinol 2024; 190:104-112. [PMID: 38291515 DOI: 10.1093/ejendo/lvae006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 01/03/2024] [Accepted: 01/08/2024] [Indexed: 02/01/2024]
Abstract
OBJECTIVE To assess the association between fructose consumption and serum sex hormone-binding globulin (SHBG), (free) testosterone, and risk of hyperandrogenism in a population-based cohort. DESIGN An observational and genetic association study in participants of the UK Biobank (n = 136 384 and n = 383 392, respectively). METHODS We assessed the relationship of (1) the intake of different sources of fructose (ie, total, fruit, fruit juice, and sugar-sweetened beverages [SSBs]) and (2) rs2304681 (a missense variant in the gene encoding ketohexokinase, used as an instrument of impaired fructose metabolism), with SHBG, total and free testosterone levels, and risk of hyperandrogenism (free androgen index >4.5). RESULTS The intake of total fructose and fructose from fruit was associated with higher serum SHBG and lower free testosterone in men and women and lower risk of hyperandrogenism in women. In contrast, fructose intake from SSB (≥10 g/day) was associated with lower SHBG in men and women and with higher free testosterone levels and risk of hyperandrogenism in women (odds ratio [OR]: 1.018; 95% confidence interval [CI]: 1.010; 1.026). Carriers of the rs2304681 A allele were characterized by higher circulating SHBG (both men and women), lower serum free testosterone (women), and a lower risk of biochemical hyperandrogenism (OR: 0.997, 95% CI: 0.955; 0.999; women) and acne vulgaris (OR: 0.975, 95% CI: 0.952; 0.999; men and women combined). CONCLUSIONS The consumption of ≥10 g/day fructose from SSB, corresponding to ≥200 mL serving, is associated with a 2% higher risk of hyperandrogenism in women. These observational data are supported by our genetic data.
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Affiliation(s)
- Huadong Chen
- Department of Internal Medicine, Division of Endocrinology and Metabolic Diseases, Maastricht University Medical Center, Maastricht, The Netherlands
- Laboratory for Metabolism and Vascular Medicine, Maastricht University, Maastricht, The Netherlands
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Amée M Buziau
- Department of Internal Medicine, Division of Endocrinology and Metabolic Diseases, Maastricht University Medical Center, Maastricht, The Netherlands
- Laboratory for Metabolism and Vascular Medicine, Maastricht University, Maastricht, The Netherlands
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Miguel E Rentería
- Department of Genetics and Computational Biology, QIMR Berghofer Medical Research Institute, Brisbane, Australia
- School of Biomedical Sciences, Faculty of Health, Queensland University of Technology (QUT), Brisbane, Australia
| | - Pomme I H G Simons
- Department of Internal Medicine, Division of Endocrinology and Metabolic Diseases, Maastricht University Medical Center, Maastricht, The Netherlands
- Laboratory for Metabolism and Vascular Medicine, Maastricht University, Maastricht, The Netherlands
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Internal Medicine, Elkerliek Hospital, Helmond, The Netherlands
| | - Martijn C G J Brouwers
- Department of Internal Medicine, Division of Endocrinology and Metabolic Diseases, Maastricht University Medical Center, Maastricht, The Netherlands
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
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Buziau AM, Blokland GAM, Schalkwijk CG, Scheijen JLJM, Simons PIHG, Eussen SJPM, Dagnelie PC, van Greevenbroek MMJ, Wesselius A, Stehouwer CDA, Brouwers MCGJ. Comment on Lee et al. Relation of Change or Substitution of Low- and No-Calorie Sweetened Beverages With Cardiometabolic Outcomes: A Systematic Review and Meta-analysis of Prospective Cohort Studies. Diabetes Care 2022;45:1917-1930. Diabetes Care 2023; 46:e97-e98. [PMID: 36952606 DOI: 10.2337/dc22-1930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Affiliation(s)
- Amée M Buziau
- Department of Internal Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands
- CARIM School for Cardiovascular Disease, Maastricht University, Maastricht, the Netherlands
- Laboratory for Metabolism and Vascular Medicine, Division of General Internal Medicine, Department of Internal Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Gabriëlla A M Blokland
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands
| | - Casper G Schalkwijk
- CARIM School for Cardiovascular Disease, Maastricht University, Maastricht, the Netherlands
- Laboratory for Metabolism and Vascular Medicine, Division of General Internal Medicine, Department of Internal Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Jean L J M Scheijen
- CARIM School for Cardiovascular Disease, Maastricht University, Maastricht, the Netherlands
- Laboratory for Metabolism and Vascular Medicine, Division of General Internal Medicine, Department of Internal Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Pomme I H G Simons
- Department of Internal Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands
- CARIM School for Cardiovascular Disease, Maastricht University, Maastricht, the Netherlands
- Laboratory for Metabolism and Vascular Medicine, Division of General Internal Medicine, Department of Internal Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Simone J P M Eussen
- CARIM School for Cardiovascular Disease, Maastricht University, Maastricht, the Netherlands
- Department of Epidemiology, Maastricht University, Maastricht, the Netherlands
- CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
| | - Pieter C Dagnelie
- Department of Internal Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands
- CARIM School for Cardiovascular Disease, Maastricht University, Maastricht, the Netherlands
| | - Marleen M J van Greevenbroek
- CARIM School for Cardiovascular Disease, Maastricht University, Maastricht, the Netherlands
- Laboratory for Metabolism and Vascular Medicine, Division of General Internal Medicine, Department of Internal Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Anke Wesselius
- NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
- Department of Complex Genetics and Epidemiology Maastricht University, Maastricht, the Netherlands
| | - Coen D A Stehouwer
- Department of Internal Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands
- CARIM School for Cardiovascular Disease, Maastricht University, Maastricht, the Netherlands
| | - Martijn C G J Brouwers
- Department of Internal Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands
- CARIM School for Cardiovascular Disease, Maastricht University, Maastricht, the Netherlands
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Ren Z, Simons PIHG, Wesselius A, Stehouwer CDA, Brouwers MCGJ. Relationship between NAFLD and coronary artery disease: A Mendelian randomization study. Hepatology 2023; 77:230-238. [PMID: 35441719 PMCID: PMC9970021 DOI: 10.1002/hep.32534] [Citation(s) in RCA: 37] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 04/05/2022] [Accepted: 04/16/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND AIMS There is an ongoing debate on whether NAFLD is an active contributor or an innocent bystander in the pathogenesis of coronary artery disease (CAD). The aim of the present study was to assess the causal relationship between NAFLD and CAD. APPROACH AND RESULTS We performed two-sample Mendelian randomization (MR) analyses using summary-level data to assess the association between genetically predicted NAFLD (i.e., chronically elevated serum alanine aminotransferase levels [cALT], imaging-based and biopsy-confirmed NAFLD) and risk of CAD. Analyses were repeated after exclusion of NAFLD susceptibility genes that are associated with impaired VLDL secretion.Inverse-variance weighted MR analyses showed a statistically significant association between genetically predicted cALT and risk of CAD (OR: 1.116, 95% CI: 1.039, 1.199), but not for the other NAFLD-related traits (OR: 1.046, 95% CI: 0.764, 1.433 and OR: 1.014, 95% CI: 0.968, 1.062 for imaging-based and biopsy-confirmed NAFLD, respectively). MR-Egger regression revealed a statistically significant intercept, indicative of directional pleiotropy, for all traits. Repeat analyses after exclusion of genes associated with impaired VLDL secretion showed consistent associations between genetically predicted NAFLD and CAD for all traits (i.e., cALT [OR: 1.203, 95% CI: 1.113, 1.300]), imaging-based (OR: 2.149, 95% CI: 1.276, 3.620) and biopsy-confirmed NAFLD (OR: 1.113, 95% CI: 1.041, 1.189), which persisted when more stringent biopsy-confirmed NAFLD criteria were used (OR: 1.154, 95% CI: 1.043, 1.278) or when more stringent MR methods were applied. MR-Egger regression did not show a statistically significant intercept. CONCLUSION The two-sample MR analyses showed a robust association between genetically predicted NAFLD and CAD after exclusion of genetic variants that are implicated in impaired VLDL secretion.
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Affiliation(s)
- Zhewen Ren
- Division of Endocrinology and Metabolic Diseases, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- Laboratory for Metabolism and Vascular Medicine, Maastricht University, Maastricht, The Netherlands
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Pomme I. H. G. Simons
- Division of Endocrinology and Metabolic Diseases, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- Laboratory for Metabolism and Vascular Medicine, Maastricht University, Maastricht, The Netherlands
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Anke Wesselius
- NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
- Department of Epidemiology, Maastricht University, Maastricht, the Netherlands
| | - Coen D. A. Stehouwer
- Laboratory for Metabolism and Vascular Medicine, Maastricht University, Maastricht, The Netherlands
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
- Division of General Internal Medicine, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Martijn C. G. J. Brouwers
- Division of Endocrinology and Metabolic Diseases, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
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Simons PIHG, Valkenburg O, van de Waarenburg MPH, van Greevenbroek MMJ, Kooi ME, Jansen JFA, Schalkwijk CG, Stehouwer CDA, Brouwers MCGJ. Serum sex hormone-binding globulin is a mediator of the association between intrahepatic lipid content and type 2 diabetes: the Maastricht Study. Diabetologia 2023; 66:213-222. [PMID: 36114428 PMCID: PMC9729158 DOI: 10.1007/s00125-022-05790-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 07/28/2022] [Indexed: 12/14/2022]
Abstract
AIMS/HYPOTHESIS Serum sex hormone-binding globulin (SHBG) has been proposed to act as a hepatokine that contributes to the extrahepatic complications observed in non-alcoholic fatty liver disease (NAFLD). However, it remains uncertain whether serum SHBG mediates the association between intrahepatic lipids (IHL) and type 2 diabetes. Therefore, we studied whether, and to what extent, serum SHBG mediates the association between IHL content and type 2 diabetes. METHODS We used cross-sectional data from the Maastricht Study (n=1554), a population-based cohort study with oversampling of individuals with type 2 diabetes. Type 2 diabetes status was assessed by oral glucose tolerance test, and IHL content was measured using 3T Dixon MRI. Mediation analyses were performed to assess the role of serum SHBG in mediating the association between IHL content and type 2 diabetes. RESULTS IHL content was significantly associated with type 2 diabetes in women and men (OR 1.08 [95% CI 1.04, 1.14] and OR 1.12 [95% CI 1.08, 1.17], respectively). Serum SHBG significantly mediated the association between IHL content and type 2 diabetes. The contribution of serum SHBG was higher in women (OR 1.04 [95% CI 1.02, 1.07]; proportion mediated 50.9% [95% CI 26.7, 81.3]) than in men (OR 1.02 [95% CI 1.01, 1.03]; proportion mediated 17.2% [95% CI 9.6, 27.6]). Repeat analyses with proxies of type 2 diabetes and adjustment for covariates did not substantially affect the results. CONCLUSIONS/INTERPRETATION In this large-scale population-based cohort study, serum SHBG was found to be a mediator of the association between IHL content and type 2 diabetes. These findings extend our understanding of the potential mechanisms by which NAFLD is a risk factor for type 2 diabetes, and further elaborate on the role of SHBG as a hepatokine.
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Affiliation(s)
- Pomme I H G Simons
- Department of Internal Medicine, Division of Endocrinology and Metabolic Diseases, Maastricht University Medical Centre, Maastricht, the Netherlands
- Laboratory for Metabolism and Vascular Medicine, Maastricht University, Maastricht, the Netherlands
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, the Netherlands
| | - Olivier Valkenburg
- Department of Reproductive Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Marjo P H van de Waarenburg
- Laboratory for Metabolism and Vascular Medicine, Maastricht University, Maastricht, the Netherlands
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, the Netherlands
| | - Marleen M J van Greevenbroek
- Laboratory for Metabolism and Vascular Medicine, Maastricht University, Maastricht, the Netherlands
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, the Netherlands
| | - M Eline Kooi
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, the Netherlands
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Jacobus F A Jansen
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands
- School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
- Department of Electrical Engineering, University of Eindhoven, Eindhoven, the Netherlands
| | - Casper G Schalkwijk
- Laboratory for Metabolism and Vascular Medicine, Maastricht University, Maastricht, the Netherlands
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, the Netherlands
| | - Coen D A Stehouwer
- Laboratory for Metabolism and Vascular Medicine, Maastricht University, Maastricht, the Netherlands
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, the Netherlands
- Department of Internal Medicine, Division of General Internal Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Martijn C G J Brouwers
- Department of Internal Medicine, Division of Endocrinology and Metabolic Diseases, Maastricht University Medical Centre, Maastricht, the Netherlands.
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, the Netherlands.
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Ren Z, Simons PIHG, Wesselius A, Stehouwer CDA, Brouwers MCGJ. Reply. Hepatology 2022; 76:E129-E130. [PMID: 35689611 DOI: 10.1002/hep.32611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 06/02/2022] [Indexed: 12/08/2022]
Affiliation(s)
- Zhewen Ren
- Division of Endocrinology and Metabolic Diseases, Department of Internal MedicineMaastricht University Medical CenterMaastrichtThe Netherlands.,Laboratory for Metabolism and Vascular MedicineMaastricht UniversityMaastrichtThe Netherlands.,CARIM School for Cardiovascular DiseasesMaastricht UniversityMaastrichtThe Netherlands
| | - Pomme I H G Simons
- Division of Endocrinology and Metabolic Diseases, Department of Internal MedicineMaastricht University Medical CenterMaastrichtThe Netherlands.,Laboratory for Metabolism and Vascular MedicineMaastricht UniversityMaastrichtThe Netherlands.,CARIM School for Cardiovascular DiseasesMaastricht UniversityMaastrichtThe Netherlands
| | - Anke Wesselius
- NUTRIM School for Nutrition and Translational Research in MetabolismMaastricht UniversityMaastrichtThe Netherlands.,Department of EpidemiologyMaastricht UniversityMaastrichtThe Netherlands
| | - Coen D A Stehouwer
- Laboratory for Metabolism and Vascular MedicineMaastricht UniversityMaastrichtThe Netherlands.,CARIM School for Cardiovascular DiseasesMaastricht UniversityMaastrichtThe Netherlands.,Division of General Internal Medicine, Department of Internal MedicineMaastricht University Medical CenterMaastrichtThe Netherlands
| | - Martijn C G J Brouwers
- Division of Endocrinology and Metabolic Diseases, Department of Internal MedicineMaastricht University Medical CenterMaastrichtThe Netherlands.,CARIM School for Cardiovascular DiseasesMaastricht UniversityMaastrichtThe Netherlands
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Simons PIHG, Valkenburg O, Stehouwer CDA, Brouwers MCGJ. Association between de novo lipogenesis susceptibility genes and coronary artery disease. Nutr Metab Cardiovasc Dis 2022; 32:2883-2889. [PMID: 36182335 DOI: 10.1016/j.numecd.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 08/18/2022] [Accepted: 09/08/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND AIMS Coronary artery disease (CAD) is the principal cause of death in individuals with non-alcoholic fatty liver disease (NAFLD). The aim of this study was to use genetic epidemiology to study the association between de novo lipogenesis (DNL), one of the major pathways leading to NAFLD, and CAD risk. METHODS AND RESULTS DNL susceptibility genes were used as instruments and selected using three approaches: 1) genes that are associated with both high serum triglycerides and low sex hormone-binding globulin, both downstream consequences of DNL (unbiased approach), 2) genes that have a known role in DNL (biased approach), and 3) genes that have been associated with serum fatty acids, used as a proxy of DNL. Gene-CAD effect estimates were retrieved from the meta-analysis of CARDIoGRAM and the UK Biobank (∼76014 cases and ∼264785 controls). Effect estimates were clustered using a fixed-effects meta-analysis. Twenty-two DNL susceptibility genes were identified by the unbiased approach, nine genes by the biased approach and seven genes were associated with plasma fatty acids. Clustering of genes selected in the unbiased and biased approach showed a statistically significant association with CAD (OR:1.016, 95%CI:1.012; 1.020 and OR:1.013, 95%CI:1.007; 1.020, respectively), while clustering of fatty acid genes did not (OR:1.004, 95%CI:0.996-1.011). Subsequent exclusion of potential influential outliers did reveal a statistically significant association (OR:1.009, 95%CI:1.000; 1.018). CONCLUSIONS DNL susceptibility genes are associated with an increased risk of CAD. These findings suggest that DNL may be involved in the pathogenesis of CAD and favor further development of strategies that target NAFLD through DNL.
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Affiliation(s)
- Pomme I H G Simons
- Department of Internal Medicine, Division of Endocrinology and Metabolic Diseases, Maastricht University Medical Center, Maastricht, the Netherlands; Laboratory for Metabolism and Vascular Medicine, Maastricht University, Maastricht, the Netherlands; CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, the Netherlands
| | - Olivier Valkenburg
- Department of Reproductive Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Coen D A Stehouwer
- Laboratory for Metabolism and Vascular Medicine, Maastricht University, Maastricht, the Netherlands; CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, the Netherlands; Department of Internal Medicine, Division of General Internal Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Martijn C G J Brouwers
- Department of Internal Medicine, Division of Endocrinology and Metabolic Diseases, Maastricht University Medical Center, Maastricht, the Netherlands; CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, the Netherlands.
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Simons PIHG, Valkenburg O, Telgenkamp I, van der Waaij KM, de Groot DM, Veeraiah P, Bons JAP, Derks TGJ, Schalkwijk CG, Schrauwen-Hinderling VB, Stehouwer CDA, Brouwers MCGJ. Serum sex hormone-binding globulin levels are reduced and inversely associated with intrahepatic lipid content and saturated fatty acid fraction in adult patients with glycogen storage disease type 1a. J Endocrinol Invest 2022; 45:1227-1234. [PMID: 35132570 PMCID: PMC9098618 DOI: 10.1007/s40618-022-01753-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 01/22/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE De novo lipogenesis has been inversely associated with serum sex hormone-binding globulin (SHBG) levels. However, the directionality of this association has remained uncertain. We, therefore, studied individuals with glycogen storage disease type 1a (GSD1a), who are characterized by a genetic defect in glucose-6-phosphatase resulting in increased rates of de novo lipogenesis, to assess the downstream effect on serum SHBG levels. METHODS A case-control study comparing serum SHBG levels in patients with GSD1a (n = 10) and controls matched for age, sex, and BMI (n = 10). Intrahepatic lipid content and saturated fatty acid fraction were quantified by proton magnetic resonance spectroscopy. RESULTS Serum SHBG levels were statistically significantly lower in patients with GSD1a compared to the controls (p = 0.041), while intrahepatic lipid content and intrahepatic saturated fatty acid fraction-a marker of de novo lipogenesis-were significantly higher in patients with GSD1a (p = 0.001 and p = 0.019, respectively). In addition, there was a statistically significant, inverse association of intrahepatic lipid content and saturated fatty acid fraction with serum SHBG levels in patients and controls combined (β: - 0.28, 95% CI: - 0.47;- 0.09 and β: - 0.02, 95% CI: - 0.04;- 0.01, respectively). CONCLUSION Patients with GSD1a, who are characterized by genetically determined higher rates of de novo lipogenesis, have lower serum SHBG levels than controls.
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Affiliation(s)
- P I H G Simons
- Division of Endocrinology and Metabolic Diseases, Department of Internal Medicine, Maastricht University Medical Centre, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
- Laboratory for Metabolism and Vascular Medicine, Maastricht University, Maastricht, The Netherlands
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - O Valkenburg
- Department of Reproductive Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - I Telgenkamp
- Division of Endocrinology and Metabolic Diseases, Department of Internal Medicine, Maastricht University Medical Centre, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
- Laboratory for Metabolism and Vascular Medicine, Maastricht University, Maastricht, The Netherlands
| | - K M van der Waaij
- Division of Endocrinology and Metabolic Diseases, Department of Internal Medicine, Maastricht University Medical Centre, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
- Laboratory for Metabolism and Vascular Medicine, Maastricht University, Maastricht, The Netherlands
| | - D M de Groot
- Division of Endocrinology and Metabolic Diseases, Department of Internal Medicine, Maastricht University Medical Centre, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - P Veeraiah
- Department of Nutrition and Movement Sciences, Maastricht University, Maastricht, The Netherlands
- Department of Radiology and Nuclear Medicine, Maastricht University, Maastricht, The Netherlands
| | - J A P Bons
- Central Diagnostic Laboratory, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - T G J Derks
- Section of Metabolic Diseases, Beatrix Children's Hospital, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - C G Schalkwijk
- Laboratory for Metabolism and Vascular Medicine, Maastricht University, Maastricht, The Netherlands
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
- Division of General Internal Medicine, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - V B Schrauwen-Hinderling
- Department of Nutrition and Movement Sciences, Maastricht University, Maastricht, The Netherlands
- Department of Radiology and Nuclear Medicine, Maastricht University, Maastricht, The Netherlands
| | - C D A Stehouwer
- Laboratory for Metabolism and Vascular Medicine, Maastricht University, Maastricht, The Netherlands
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
- Division of General Internal Medicine, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - M C G J Brouwers
- Division of Endocrinology and Metabolic Diseases, Department of Internal Medicine, Maastricht University Medical Centre, PO Box 5800, 6202 AZ, Maastricht, The Netherlands.
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands.
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Simons PIHG, Cornelissen MEB, Valkenburg O, Onland‐Moret NC, van der Schouw YT, Stehouwer CD, Burgess S, Brouwers MCGJ. Causal relationship between polycystic ovary syndrome and coronary artery disease: A Mendelian randomisation study. Clin Endocrinol (Oxf) 2022; 96:599-604. [PMID: 34524719 PMCID: PMC7612926 DOI: 10.1111/cen.14593] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 07/27/2021] [Accepted: 08/02/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Polycystic ovary syndrome (PCOS) has been associated with an increased risk of coronary artery disease (CAD). However, it remains uncertain whether this increased risk is the result of PCOS per se or, alternatively, is explained by obesity, a common feature of PCOS. The aim of this study was to assess the causal association between PCOS and CAD and the role of obesity herein. DESIGN AND METHODS We conducted two-sample Mendelian randomisation analyses in large-scale, female-specific datasets to study the association between genetically predicted (1) risk of PCOS and risk of CAD, (2) body mass index (BMI) and risk of PCOS and (3) BMI and risk of CAD. Primary analyses were conducted with the inverse-variance weighted (IVW) method. Simple median, penalized weighted median and contamination mixture analyses were performed to assess the robustness of the outcomes. RESULTS IVW analyses did not show a statistically significant association between PCOS and CAD (odds ratio [OR]: 0.99, 95% confidence interval [CI]: 0.89, 1.11). In contrast, genetically predicted BMI was statistically significantly associated with an increased odds of PCOS (OR: 3.21, 95% CI: 2.26, 4.56) and CAD (OR: 1.38, 95% CI: 1.14, 1.67). Similar results were obtained when secondary analyses were performed. CONCLUSION These sex-specific analyses show that the genetically predicted risk of PCOS is not associated with the risk of CAD. Instead, the genetically predicted risk of obesity (and its downstream metabolic effects) is the common denominator of both PCOS and CAD risk.
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Affiliation(s)
- Pomme I. H. G. Simons
- Department of Internal Medicine, Division of Endocrinology and Metabolic DiseasesMaastricht University Medical CenterMaastrichtThe Netherlands
- Laboratory for Metabolism and Vascular MedicineMaastricht UniversityMaastrichtThe Netherlands
- CARIM School for Cardiovascular DiseasesMaastricht UniversityMaastrichtThe Netherlands
| | - Merel E. B. Cornelissen
- Julius Center for Health Sciences and Primary Care, University Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands
| | - Olivier Valkenburg
- Department of Reproductive MedicineMaastricht University Medical CenterMaastrichtThe Netherlands
| | - N. Charlotte Onland‐Moret
- Julius Center for Health Sciences and Primary Care, University Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands
| | - Yvonne T. van der Schouw
- Julius Center for Health Sciences and Primary Care, University Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands
| | - Coen D.A. Stehouwer
- Laboratory for Metabolism and Vascular MedicineMaastricht UniversityMaastrichtThe Netherlands
- CARIM School for Cardiovascular DiseasesMaastricht UniversityMaastrichtThe Netherlands
- Department of Internal Medicine, Division of General Internal MedicineMaastricht University Medical CenterMaastrichtThe Netherlands
| | - Stephen Burgess
- Department of Public Health and Primary CareUniversity of CambridgeCambridgeUK
- MRC Biostatistics UnitUniversity of CambridgeCambridgeUK
| | - Martijn C. G. J. Brouwers
- Department of Internal Medicine, Division of Endocrinology and Metabolic DiseasesMaastricht University Medical CenterMaastrichtThe Netherlands
- CARIM School for Cardiovascular DiseasesMaastricht UniversityMaastrichtThe Netherlands
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9
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Simons PIHG, Valkenburg O, Stehouwer CDA, Brouwers MCGJ. Sex hormone-binding globulin: biomarker and hepatokine? Trends Endocrinol Metab 2021; 32:544-553. [PMID: 34052096 DOI: 10.1016/j.tem.2021.05.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 04/19/2021] [Accepted: 05/04/2021] [Indexed: 12/18/2022]
Abstract
Over the past decade, there have been important breakthroughs in our understanding of the regulation and function of sex hormone-binding globulin (SHBG). A recent genome-wide association and Mendelian randomization study has provided new insights at the population level. Thorough study of genetic variants affecting serum SHBG has identified de novo lipogenesis as one of the mechanistic links between the metabolic syndrome and reduced serum SHBG levels in humans. Furthermore, careful deduction of the Mendelian randomization results suggests a direct, causal role for SHBG in the pathogenesis of type 2 diabetes, as a hepatokine, in women. These findings prompt the development of SHBG-raising therapies as a means to prevent or treat disorders such as type 2 diabetes and polycystic ovary syndrome.
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Affiliation(s)
- Pomme I H G Simons
- Division of Endocrinology and Metabolic Diseases, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands; Laboratory for Metabolism and Vascular Medicine, Maastricht University, Maastricht, The Netherlands; CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Olivier Valkenburg
- Department of Reproductive Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Coen D A Stehouwer
- Laboratory for Metabolism and Vascular Medicine, Maastricht University, Maastricht, The Netherlands; CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands; Division of General Internal Medicine, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Martijn C G J Brouwers
- Division of Endocrinology and Metabolic Diseases, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands; CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands.
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10
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Simons PIHG, Valkenburg O, Bons JAP, Stehouwer CDA, Brouwers MCGJ. The relationships of sex hormone-binding globulin, total testosterone, androstenedione and free testosterone with metabolic and reproductive features of polycystic ovary syndrome. Endocrinol Diabetes Metab 2021; 4:e00267. [PMID: 34277990 PMCID: PMC8279613 DOI: 10.1002/edm2.267] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 05/07/2021] [Accepted: 05/08/2021] [Indexed: 12/15/2022] Open
Abstract
Objective A recent Mendelian randomization study has suggested a causal role for sex hormone‐binding globulin (SHBG), total testosterone and free testosterone in the pathogenesis of polycystic ovary syndrome (PCOS). The aim of this study was to assess the relationships of SHBG, androstenedione, total and free testosterone with the individual metabolic and reproductive features of PCOS. Design Cross‐sectional data in PCOS patients (n=96) prospectively collected in a secondary/tertiary clinic for menstrual cycle disorders. Methods Multivariable regression analyses were conducted to study the associations between SHBG, androstenedione, total and free testosterone with metabolic (BMI, waist circumference, systolic and diastolic blood pressure, total cholesterol, LDL cholesterol, HDL cholesterol, triglycerides and homeostatic model assessment for insulin resistance [HOMA2‐IR]) and reproductive features (menstrual cycle length, antral follicle count, anti‐Müllerian hormone, luteinizing hormone, follicle‐stimulating hormone and Ferriman‐Gallwey score) of PCOS. Results Serum SHBG and free testosterone, but not total testosterone or androstenedione, were significantly associated with BMI, waist circumference, serum triglycerides, HDL cholesterol, LDL cholesterol and HOMA2‐IR. The strength of the associations with serum lipids was reduced after adjustment for BMI, but not for HOMA2‐IR. Total testosterone was significantly associated with antral follicle count. SHBG, total testosterone and androstenedione were significantly associated with serum AMH. Only the strength of the association for SHBG was reduced after adjustment for BMI. Conclusions Serum SHBG is associated with primarily metabolic features, whereas total testosterone and androstenedione are associated with reproductive features of PCOS. These results suggest a differential underlying pathophysiology for the metabolic and reproductive features of PCOS.
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Affiliation(s)
- Pomme I H G Simons
- Division of Endocrinology and Metabolic Diseases Department of Internal Medicine Maastricht University Medical Centre Maastricht The Netherlands.,Laboratory for Metabolism and Vascular Medicine Maastricht University Maastricht The Netherlands.,CARIM School for Cardiovascular Diseases Maastricht University Maastricht The Netherlands
| | - Olivier Valkenburg
- Department of Reproductive Medicine Maastricht University Medical Centre Maastricht The Netherlands
| | - Judith A P Bons
- Central Diagnostic Laboratory Maastricht University Medical Centre Maastricht The Netherlands
| | - Coen D A Stehouwer
- Laboratory for Metabolism and Vascular Medicine Maastricht University Maastricht The Netherlands.,CARIM School for Cardiovascular Diseases Maastricht University Maastricht The Netherlands.,Division of General Internal Medicine Department of Internal Medicine Maastricht University Medical Centre Maastricht The Netherlands
| | - Martijn C G J Brouwers
- Division of Endocrinology and Metabolic Diseases Department of Internal Medicine Maastricht University Medical Centre Maastricht The Netherlands.,CARIM School for Cardiovascular Diseases Maastricht University Maastricht The Netherlands
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11
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Simons PIHG, Valkenburg O, Telgenkamp I, van der Waaij KM, de Groot DM, Veeraiah P, Bons JAP, Taskinen M, Borén J, Schrauwen P, Rutten JHW, Cassiman D, Schalkwijk CG, Stehouwer CDA, Schrauwen‐Hinderling VB, Hodson L, Brouwers MCGJ. Relationship between de novo lipogenesis and serum sex hormone binding globulin in humans. Clin Endocrinol (Oxf) 2021; 95:101-106. [PMID: 33715205 PMCID: PMC8287427 DOI: 10.1111/cen.14459] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 02/03/2021] [Accepted: 03/01/2021] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Obesity and liver fat are associated with decreased levels of serum sex hormone binding globulin (SHBG). Laboratory studies suggest that hepatic de novo lipogenesis (DNL) is involved in the downregulation of SHBG synthesis. The aim of the present study was to address the role of DNL on serum SHBG in humans. DESIGN A cross-sectional study examining the association between DNL, measured by stable isotopes, and serum SHBG, stratified by sex. PARTICIPANTS Healthy men (n = 34) and women (n = 21) were combined from two cross-sectional studies. Forty-two per cent of participants had hepatic steatosis, and the majority were overweight (62%) or obese (27%). RESULTS DNL was inversely associated with SHBG in women (β: -0.015, 95% CI: -0.030; 0.000), but not in men (β: 0.007, 95% CI: -0.005; 0.019) (p for interaction = .068). Adjustment for study population, age and body mass index did not materially change these results, although statistical significance was lost after adjustment for serum insulin. CONCLUSIONS An inverse association between DNL and SHBG may explain the decreased SHBG levels that are observed in obesity, at least in women.
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Affiliation(s)
- Pomme I. H. G. Simons
- Division of Endocrinology and Metabolic DiseasesDepartment of Internal MedicineMaastricht University Medical CentreMaastrichtThe Netherlands
- Laboratory for Metabolism and Vascular MedicineMaastricht UniversityMaastrichtThe Netherlands
- CARIM School for Cardiovascular DiseasesMaastricht UniversityMaastrichtThe Netherlands
| | - Olivier Valkenburg
- Department of Reproductive MedicineMaastricht University Medical CentreMaastrichtThe Netherlands
| | - Ine Telgenkamp
- Division of Endocrinology and Metabolic DiseasesDepartment of Internal MedicineMaastricht University Medical CentreMaastrichtThe Netherlands
- Laboratory for Metabolism and Vascular MedicineMaastricht UniversityMaastrichtThe Netherlands
| | - Koen M. van der Waaij
- Division of Endocrinology and Metabolic DiseasesDepartment of Internal MedicineMaastricht University Medical CentreMaastrichtThe Netherlands
- Laboratory for Metabolism and Vascular MedicineMaastricht UniversityMaastrichtThe Netherlands
| | - David M. de Groot
- Division of Endocrinology and Metabolic DiseasesDepartment of Internal MedicineMaastricht University Medical CentreMaastrichtThe Netherlands
| | - Pandichelvam Veeraiah
- Department of Nutrition and Movement SciencesMaastricht UniversityMaastrichtNetherlands
- Department of Radiology and Nuclear MedicineMaastricht UniversityMaastrichtNetherlands
| | - Judith A. P. Bons
- Central Diagnostic LaboratoryMaastricht University Medical CentreMaastrichtNetherlands
| | - Marja‐Riitta Taskinen
- Research Program, Unit Clinical and Molecular MetabolismUniversity of HelsinkiHelsinkiFinland
| | - Jan Borén
- Department of Molecular and Clinical MedicineUniversity of GothenburgGothenburgSweden
| | - Patrick Schrauwen
- Department of Nutrition and Movement SciencesMaastricht UniversityMaastrichtNetherlands
| | - Joost H. W. Rutten
- Department of Internal MedicineRadboud University Medical CentreNijmegenThe Netherlands
| | - David Cassiman
- Department of Gastroenterology‐Hepatology and Metabolic CentreUniversity Hospital LeuvenLeuvenBelgium
| | - Casper G. Schalkwijk
- Laboratory for Metabolism and Vascular MedicineMaastricht UniversityMaastrichtThe Netherlands
- CARIM School for Cardiovascular DiseasesMaastricht UniversityMaastrichtThe Netherlands
| | - Coen D. A. Stehouwer
- Laboratory for Metabolism and Vascular MedicineMaastricht UniversityMaastrichtThe Netherlands
- CARIM School for Cardiovascular DiseasesMaastricht UniversityMaastrichtThe Netherlands
- Division of General Internal MedicineDepartment of Internal MedicineMaastricht University Medical CentreMaastrichtThe Netherlands
| | - Vera B. Schrauwen‐Hinderling
- Department of Nutrition and Movement SciencesMaastricht UniversityMaastrichtNetherlands
- Department of Radiology and Nuclear MedicineMaastricht UniversityMaastrichtNetherlands
| | - Leanne Hodson
- Oxford Centre for Diabetes, Endocrinology and MetabolismUniversity of OxfordOxfordUnited Kingdom
- National Institute for Health Research Oxford Biomedical Research CentreOxford University Hospitals Foundation TrustOxfordUnited Kingdom
| | - Martijn C. G. J. Brouwers
- Division of Endocrinology and Metabolic DiseasesDepartment of Internal MedicineMaastricht University Medical CentreMaastrichtThe Netherlands
- CARIM School for Cardiovascular DiseasesMaastricht UniversityMaastrichtThe Netherlands
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12
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Simons N, Veeraiah P, Simons PIHG, Schaper NC, Kooi ME, Schrauwen-Hinderling VB, Feskens EJM, van der Ploeg EMC(L, Van den Eynde MDG, Schalkwijk CG, Stehouwer CDA, Brouwers MCGJ. Effects of fructose restriction on liver steatosis (FRUITLESS); a double-blind randomized controlled trial. Am J Clin Nutr 2020; 113:391-400. [PMID: 33381794 PMCID: PMC7851818 DOI: 10.1093/ajcn/nqaa332] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 10/21/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND There is an ongoing debate on whether fructose plays a role in the development of nonalcoholic fatty liver disease. OBJECTIVES The aim of this study was to investigate the effects of fructose restriction on intrahepatic lipid (IHL) content in a double-blind randomized controlled trial using an isocaloric comparator. METHODS Between March 2017 and October 2019, 44 adult overweight individuals with a fatty liver index ≥ 60 consumed a 6-wk fructose-restricted diet (<7.5 g/meal and <10 g/d) and were randomly assigned to supplementation with sachets of glucose (= intervention group) or fructose (= control group) 3 times daily. Participants and assessors were blinded to the allocation. IHL content, assessed by proton magnetic resonance spectroscopy, was the primary outcome and glucose tolerance and serum lipids were the secondary outcomes. All measurements were conducted in Maastricht University Medical Center. RESULTS Thirty-seven participants completed the study protocol. After 6 wk of fructose restriction, dietary fructose intake and urinary fructose excretion were significantly lower in the intervention group (difference: -57.0 g/d; 95% CI: -77.9, -39.5 g/d; and -38.8 μmol/d; 95% CI: -91.2, -10.7 μmol/d, respectively). Although IHL content decreased in both the intervention and control groups (P < 0.001 and P = 0.003, respectively), the change in IHL content was more pronounced in the intervention group (difference: -0.7% point, 95% CI: -2.0, -0.03% point). The changes in glucose tolerance and serum lipids were not significantly different between groups. CONCLUSIONS Six weeks of fructose restriction per se led to a small, but statistically significant, decrease in IHL content in comparison with an isocaloric control group.This trial was registered at clinicaltrials.gov as NCT03067428.
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Affiliation(s)
- Nynke Simons
- Division of Endocrinology and Metabolic Diseases, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands,Laboratory for Metabolism and Vascular Medicine, Division of General Internal Medicine, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands,CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Pandichelvam Veeraiah
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands,NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht, The Netherlands
| | - Pomme I H G Simons
- Division of Endocrinology and Metabolic Diseases, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands,Laboratory for Metabolism and Vascular Medicine, Division of General Internal Medicine, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands,CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Nicolaas C Schaper
- Division of Endocrinology and Metabolic Diseases, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands,CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands,CAPHRI School for Public Health and Primary Care, Maastricht, The Netherlands
| | - M Eline Kooi
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands,NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht, The Netherlands
| | - Vera B Schrauwen-Hinderling
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands,NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht, The Netherlands,Department of Nutrition and Movement Sciences, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Edith J M Feskens
- Division of Human Nutrition and Health, Wageningen University, Wageningen, The Netherlands
| | | | - Mathias D G Van den Eynde
- Laboratory for Metabolism and Vascular Medicine, Division of General Internal Medicine, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands,CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Casper G Schalkwijk
- Laboratory for Metabolism and Vascular Medicine, Division of General Internal Medicine, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands,CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Coen D A Stehouwer
- Laboratory for Metabolism and Vascular Medicine, Division of General Internal Medicine, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands,CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands,Division of General Internal Medicine, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
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