Publications by authors named "Nagila Raquel Teixeira Damasceno"

35 Publications

Bioelectrical impedance vector applied to body composition evaluation of women survivors of breast cancer: A longitudinal study.

Clin Nutr ESPEN 2021 08 19;44:247-253. Epub 2021 Jun 19.

Postgraduate Program in Nutrition and Health, State University of Ceara, Fortaleza, Ceara, Brazil. Electronic address:

Background And Aims: Thus, the aim of this study was to assess the changes in the body composition of the women survivors of breast cancer and its association with clinical staging, using the bioelectrical impedance vector analysis (BIVA), over five years of follow-up.

Methods: At baseline time 114 patients (T0) were selected and after 5 years (T1) of follow-up (n = 35) data of weight, body mass index, waist circumference, phase angle, resistance/height, reactance/height, %fat free mass and %fat mass were monitored. Bioelectrical impedance vector analysis (BIVA) and the vector displacement assessment took place according to the initial and advanced clinical staging (CS 1 and 2, respectively) and time of follow-up and have been showed using mean graph and RXc score graph.

Results: Patients on CS 1 showed a reduction in reactance/height, phase angle, %fat free mass and an increase in %fat mass. The same group presented during the follow-up significant vector displacement by mean graph and a change to the 95% ellipse by the RXc score graph.

Conclusions: Women with breast cancer in the initial CS showed a more significant displacement of bioelectric vectors, indicating worsening in body composition.
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http://dx.doi.org/10.1016/j.clnesp.2021.06.008DOI Listing
August 2021

Cardiovascular risk estimated in individuals with multiple sclerosis: A case-control study.

Mult Scler Relat Disord 2021 Jul 3;54:103133. Epub 2021 Jul 3.

Postgraduate Program in Nutrition and Health, Ceara State University (UECE), Fortaleza, Brazil; Postgraduate Program in Applied Human Nutrition (PRONUT), Department of Nutrition, School of Public Health, University of São Paulo (USP), São Paulo, Brazil; Multiple Sclerosis Interdisciplinary Center, Neurology Department, Fortaleza General Hospital (HGF-SUS), Fortaleza, Brazil. Electronic address:

Background: Patients with multiple sclerosis (MS) had a 1.5-fold increase in cardiovascular diseases (CVD) mortality, compared with those without MS. Therefore, the aim of this study was to assess the CVD risk in MS patients by multiple cardiometabolic indexes and to investigate associated factors.

Methods: The MS group included 57 patients matched for age and sex to 57 healthy controls. They were evaluated for physical activity, smoking, anthropometric indices, blood pressure, and plasma biomarkers. Framingham risk score (FRS) and multiple cardiovascular risk indexes were calculated. Clinical course of disease, age at onset, disease duration, disease-modifying therapy, relapse rate, EDSS, physical and functional impairment were investigated.

Results: The mean age was 34.6 years old. The majority (89.5%) in the MS group had a RRMS clinical course and a mild level of disability (EDSS=1.0). WC (p = 0.022) and FM% (p = 0.007) were different between the MS and control groups. The FRS was higher in the MS group (10% versus 0%) and this was related with high prevalence of dyslipidemia (43.8% versus 36.8%). The atherogenic index of plasma (AIP) (0.013) and Castelli risk indexes I (CRI-I) (p = 0.017) and II (CRI-II) (p = 0.008) and non-HDL-C (p = 0.044) were higher in the MS group.

Conclusion: MS patients, with controlled disease course, have a higher cardiovascular risk than comparable healthy individuals. We emphasize that the use of FRS, and the monitoring of CRI-I and II, as well as AIP, are important lipid markers to manage CVD risk in individuals with MS.
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http://dx.doi.org/10.1016/j.msard.2021.103133DOI Listing
July 2021

Omega-3 Fatty Acids in Erythrocyte Membranes as Predictors of Lower Cardiovascular Risk in Adults without Previous Cardiovascular Events.

Nutrients 2021 Jun 3;13(6). Epub 2021 Jun 3.

Department of Nutrition, School of Public Health, University of São Paulo, São Paulo 01246-904, Brazil.

This study investigated the association of omega-3 polyunsaturated fatty acids (-3 PUFA) within erythrocyte membranes and cardiovascular risk assessed by three different estimates. Inclusion criteria were individuals of both sexes, 30 to 74 years, with at least one cardiovascular risk factor, and no previous cardiovascular events ( = 356). Exclusion criteria were individuals with acute or chronic severe diseases, infectious diseases, pregnant, and/or lactating women. Plasma biomarkers (lipids, glucose, and -reactive protein) were analyzed, and nineteen erythrocyte membrane fatty acids (FA) were identified. The cardiovascular risk was estimated by Framingham (FRS), Reynolds (RRS), and ACC/AHA-2013 Risk Scores. Three patterns of FA were identified (Factor 1, poor in -3 PUFA), (Factor 2, poor in PUFA), and (Factor 3, rich in -3 PUFA). Total cholesterol was inversely correlated with erythrocyte membranes C18:3 -3 (r = -0.155; = 0.004), C22:6 -3 (r = -0.112; = 0.041), and total -3 (r = -0.211; < 0.001). Total -3 PUFA was associated with lower cardiovascular risk by FRS (OR = 0.811; 95% CI= 0.675-0.976). Regarding RRS, Factor 3 was associated with 25.3% lower odds to have moderate and high cardiovascular risk (OR = 0.747; 95% CI = 0.589-0.948). The ACC/AHA-2013 risk score was not associated with isolated and pooled FA. -3 PUFA in erythrocyte membranes are independent predictors of low-risk classification estimated by FRS and RRS, which could be explained by cholesterol-lowering effects of -3 PUFA.
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http://dx.doi.org/10.3390/nu13061919DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8227633PMC
June 2021

A Ketogenic Low-Carbohydrate High-Fat Diet Increases LDL Cholesterol in Healthy, Young, Normal-Weight Women: A Randomized Controlled Feeding Trial.

Nutrients 2021 Mar 2;13(3). Epub 2021 Mar 2.

Department of Food, Nutrition and Culinary Science, Umeå University, 90187 Umeå, Sweden.

Ketogenic low-carbohydrate high-fat (LCHF) diets are popular among young, healthy, normal-weight individuals for various reasons. We aimed to investigate the effect of a ketogenic LCHF diet on low-density lipoprotein (LDL) cholesterol (primary outcome), LDL cholesterol subfractions and conventional cardiovascular risk factors in the blood of healthy, young, and normal-weight women. The study was a randomized, controlled, feeding trial with crossover design. Twenty-four women were assigned to a 4 week ketogenic LCHF diet (4% carbohydrates; 77% fat; 19% protein) followed by a 4 week National Food Agency recommended control diet (44% carbohydrates; 33% fat; 19% protein), or the reverse sequence due to the crossover design. Treatment periods were separated by a 15 week washout period. Seventeen women completed the study and treatment effects were evaluated using mixed models. The LCHF diet increased LDL cholesterol in every woman with a treatment effect of 1.82 mM ( < 0.001). In addition, Apolipoprotein B-100 (ApoB), small, dense LDL cholesterol as well as large, buoyant LDL cholesterol increased ( < 0.001, < 0.01, and < 0.001, respectively). The data suggest that feeding healthy, young, normal-weight women a ketogenic LCHF diet induces a deleterious blood lipid profile. The elevated LDL cholesterol should be a cause for concern in young, healthy, normal-weight women following this kind of LCHF diet.
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http://dx.doi.org/10.3390/nu13030814DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8001988PMC
March 2021

Micronutrient supplementation needs more attention in patients with refractory epilepsy under ketogenic diet treatment.

Nutrition 2021 06 29;86:111158. Epub 2021 Jan 29.

Department of Nutrition, School of Public Health, University of São Paulo, São Paulo, Brazil. Electronic address:

Objectives: This study evaluated the adequacy of micronutrient intake from the ketogenic diet (KD) with and without micronutrient supplementation according to age in Brazilian children and adolescents with refractory epilepsy undergoing KD treatment.

Methods: This study enrolled children and adolescents with refractory epilepsy who were up to 19 y of age. Nutrient intakes were monitored using 3 d food records before introducing micronutrient supplementation and 3 mo after starting KD treatment. The prevalence of micronutrient inadequacy was estimated by sex and age according to the estimated average requirement cutoff values.

Results: This study included 39 children and adolescents. The KD did not provide enough content of folate, calcium, and magnesium in all patients according to the dietary reference intake. Even after starting supplementation, calcium, phosphorus, and magnesium intake remained inadequate in the majority of patients. The supplementation effectively met the vitamin B recommendation in all age groups.

Conclusions: KD treatment did not provide adequate levels of the monitored micronutrients. The supplementation improved but did not prevent the inadequacy of micronutrients such as calcium, magnesium, and phosphorus. The results highlight the importance of individual supplementation protocols and the need to monitor micronutrient intake according to age and sex.
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http://dx.doi.org/10.1016/j.nut.2021.111158DOI Listing
June 2021

Higher bodily adiposity, fat intake, and cholesterol serum levels are associated with higher disease activity in psoriatic arthritis patients: is there a link among fat and skin and joint involvement?

Lipids Health Dis 2020 Feb 7;19(1):21. Epub 2020 Feb 7.

Federal University of Sao Paulo (UNIFESP/ EPM). Rheumatology Division, 204 Leandro Dupré St., Room 74, Vila Clementino, Sao Paulo, 04025-010, Brazil.

Introduction/ Objectives: Assuming that there is a link between lipid and glucose metabolism and inflammation in patients with psoriatic arthritis (PsA), our aim was to evaluate the relationships among body composition measurements, food intake, and disease activity in patients with PsA.

Methods: A total of 97 patients with PsA, according to the CASPAR criteria, were included in this cross-sectional study. Body composition measurements (whole-body DXA, GE-Lunar), food intake (3-day registry) and biochemical and inflammatory serum markers were evaluated. Skin and joint disease activity were assessed by using PASI, BSA, DAS28, and minimal disease activity (MDA). The level of significance was set as p < 0.05.

Results: A higher prevalence of obesity, according to the fat mass index (FMI) (92.7%), and metabolic syndrome (MetS) (54%) were found, but no significant changes regarding lean or bone mass were found. Joint disease activity was positively correlated with total body fat (r = 0.4; p < 0.001), FMI (r = 0.33; p < 0.001), body mass index (r = 0.20; p < 0.049) and waist circumference (r = 0.27; p = 0.009). In addition, joint disease activity was negatively associated with muscle mass (r = - 0.38; p < 0.001). Skin disease activity was positively correlated with total cholesterol (r = 0.3; p = 0.003) and LDL-cholesterol (r = 0.28; p = 0.006). After multiple adjustments, patients with severe joint disease activity had higher body adiposity than patients in remission or with low disease activity. Skin disease activity was associated with higher trans-fat intake and lower omega-6 consumption.

Conclusions: Our data suggest a possible harmful link among fat (body adiposity, saturated fat consumption, LDL-cholesterol serum levels) and joint and skin disease activity in patients with PsA.
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http://dx.doi.org/10.1186/s12944-020-1200-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7006378PMC
February 2020

OxLDL alterations in endothelial cell membrane dynamics leads to changes in vesicle trafficking and increases cell susceptibility to injury.

Biochim Biophys Acta Biomembr 2020 03 5;1862(3):183139. Epub 2019 Dec 5.

Department of Morphology, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil. Electronic address:

Plasma membrane repair (PMR) is an important process for cell homeostasis, especially for cells under constant physical stress. Repair involves a sequence of Ca-dependent events, including lysosomal exocytosis and subsequent compensatory endocytosis. Cholesterol sequestration from plasma membrane causes actin cytoskeleton reorganization and polymerization, increasing cell stiffness, which leads to exocytosis and reduction of a peripheral pool of lysosomes involved in PMR. These changes in mechanical properties are similar to those observed in cells exposed to oxidized Low Density Lipoprotein (oxLDL), a key molecule during atherosclerosis development. Using a human umbilical vein endothelial cell line (EAhY926) we evaluated the influence of mechanical modulation induced by oxLDL in PMR and its effect in endothelial fragility. Similar to MβCD (a drug capable of sequestering cholesterol) treatment, oxLDL exposure led to actin reorganization and de novo polymerization, as well as an increase in cell rigidity and lysosomal exocytosis. Additionally, for both MβCD and oxLDL treated cells, there was an initial increase in endocytic events, likely triggered by the peak of exocytosis induced by both treatments. However, no further endocytic events were observed, suggesting that constitutive endocytosis is blocked upon treatment and that the reorganized cytoskeleton function as a mechanical barrier to membrane traffic. Finally, the increase in cell rigidity renders cells more prone to mechanical injury. Together, these data show that mechanical modulation induced by oxLDL exposure not only alters membrane traffic in cells, but also makes them more susceptible to mechanical injury, which may likely contribute to the initial steps of atherosclerosis development.
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http://dx.doi.org/10.1016/j.bbamem.2019.183139DOI Listing
March 2020

Comparison of early cardiovascular risk among Brazilian and African university students.

Clin Biochem 2020 Jan 1;75:7-14. Epub 2019 Nov 1.

Department of Clinical and Toxicological Analysis, Federal University of Ceará, Fortaleza, Ceará, Brazil.

Cardiovascular diseases are among the main causes of mortality worldwide, and dyslipidemia is a principal factor risk. Hence the study of biochemical markers is necessary for early diagnosis.

Objectives: Evaluate biomarkers to diagnose the risks of cardiovascular diseases in healthy Brazilian and African young adults.

Design & Methods: Weight, height, waist circumference, percentage of body fat and systemic blood pressure were measured; and fasting blood samples were taken for biochemical analysis. Triglycerides, total cholesterol, HDL-c, and apolipoproteins A-I and B were measured on automated equipment using commercially available kits, in addition to the tests of antioxidant capacity of HDL and the enzymatic activity of Paraoxonase 1.

Results: After statistical analysis, it was found that BMI, WC, fat (%), triglycerides, ApoB/ApoA-I ratio and Vmax were higher in Brazilians, while HDL-c, ApoA-I, Lag Time, Vmax and PON1 activity were higher in Africans. In Brazilians, the ApoB/ApoA-I ratio was related to obesity factors and lipid profile, but in Africans it was related only to lipids. The antioxidant capacity of HDL and PON1 activity was better in Africans. Through independence testing, we observed an association with moderate risk of myocardial infarction with gender in Africans. In the binary logistic regression analysis, it was found that men in general - and particularly African men - have higher risk of myocardial infarction than women; Odds Ratio 2144 (CI: 1343-3424) and 2281 (CI: 1082-4811), respectively.

Conclusions: The anthropometric and biochemical parameters of Brazilians, especially men, predispose them to greater risks of cardiovascular diseases.
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http://dx.doi.org/10.1016/j.clinbiochem.2019.09.007DOI Listing
January 2020

A possible link between polyunsaturated fatty acids and uremic toxins from the gut microbiota in hemodialysis patients: A hypothesis.

Hemodial Int 2019 04 19;23(2):189-197. Epub 2019 Feb 19.

Post-Graduate Program in Medical Sciences, Federal University Fluminense (UFF), Niterói, Rio de Janeiro, Brazil.

Introduction: Indoxyl sulfate (IS) and p-cresyl sulfate (p-CS) are albumin-bound uremic toxins that are difficult to remove by hemodialysis (HD). Human serum albumin (HSA) carries several compounds, including fatty acids that can bind to site II of HSA and represent competing ligands for uremic toxins. The aim of this study was to investigate the association between fatty acids and uremic toxin plasma levels in patients undergoing HD.

Methods: Thirty-three HD patients (51.5% male, 54.9 ± 10.2 years old, 44.63 ± 28.4 months on HD, albumin level of 3.8 ± 0.3 g/dL) were evaluated. The erythrocyte fatty acid content (saturated fatty acid [SFA], monounsaturated fatty acid [MUFA], and polyunsaturated fatty acid [PUFA]) was measured by gas chromatography, and total IS and p-CS plasma levels were measured by reversed-phase high-performance liquid chromatography.

Findings: The mean percentages of docosahexaenoic acid (DHA), eicosapentaenoic acid (EPA) + DHA and gamma-linolenic (GLA) acid in the erythrocyte membrane were 1.35% ± 0.74%, 1.85% ± 0.79%, and 0.33% ± 0.26%, respectively. The mean levels of IS and p-CS were 19.4 ± 11.9 mg/dL and 101.5 ± 57.2 mg/dL, respectively. There was no significant association between SFA and MUFA and IS and p-CS; however, a negative correlation was found between p-CS and specific PUFAs, and the association between GLA and p-CS levels was retained after adjusting for potential confounding variables (β = -0.49, P = 0.007).

Discussion: Polyunsaturated fatty acids may contribute to the decrease in p-CS uremic toxin plasma levels in patients with chronic kidney disease undergoing HD.
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http://dx.doi.org/10.1111/hdi.12725DOI Listing
April 2019

Plasma and erythrocyte ω-3 and ω-6 fatty acids are associated with multiple inflammatory and oxidative stress biomarkers in breast cancer.

Nutrition 2019 02 21;58:194-200. Epub 2018 Aug 21.

Nutrition Department, Faculdade de Saúde Pública, Universidade de São Paulo, São Paulo, Brazil. Electronic address:

Objectives: The aim of this study was to assess the association of plasma and erythrocyte ω-3 and ω-6 fatty acids with multiple oxidative stress biomarkers in breast cancer patients.

Methods: Ninety-five women with recently diagnosed breast cancer and no previous treatment were selected for this study. The socioeconomic, clinical, and demographic profile of the patients was determined using a structured questionnaire and medical records. Body weight and height were measured to calculate body mass index. Blood samples were drawn after a 12-h fast for biochemical analyses. The oxidative stress biomarkers low-density lipoprotein (-) and its anti-low-density lipoprotein (-) antibodies, α-tocopherol, β-carotene, high-density lipoprotein cholesterol, thiobarbituric acid reactive substance, and adiponectin were measured. Plasma and erythrocyte fatty acids were assessed by gas chromatography. Factor and principal component analysis was used to identify three factors called factor 1 (anti-inflammatory), factor 2 (antioxidant), and factor 3 (oxidant). Linear regression, adjusted for confounding variables, was used to estimate the association of these factors with plasma and erythrocyte ω-3 and ω-6 fatty acids and their ratios.

Results: ω-3 series fatty acids showed a positive association with Factor 1. A positive association of plasma and erythrocyte ω-6 fatty acids with factors 1 and 2, respectively, was found. ω-6/ω-3 ratio (plasma) was inversely associated with the anti-inflammatory factor.

Conclusion: Polyunsaturated fatty acids of the plasma and erythrocyte ω-3 and ω-6 series were associated with multiple inflammatory and oxidative stress biomarkers in breast cancer.
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http://dx.doi.org/10.1016/j.nut.2018.07.115DOI Listing
February 2019

Plasma fatty acids: Biomarkers of dietary intake?

Nutrition 2019 03 22;59:77-82. Epub 2018 Aug 22.

Department of Nutrition, School of Public Health, University of Sao Paulo, Sao Paulo, Brazil.

Objective: To our knowledge, there is currently no consensus in the literature on the association between dietary fatty acids and circulating levels in plasma. The aim of this study was to assess the association of the intake of fatty acids with their relative plasma concentrations.

Methods: We conducted a study with 300 adults from the population-based health survey in São Paulo city (ISA-Capital 2008). We assessed demographic, lifestyle and anthropometric data, biochemical measurements, and two 24-h dietary recalls collected on non-consecutive days. Intake distribution was adjusted for intrapersonal variance to give usual dietary intake using the multiple source method (MSM). Percentage of fatty acids in plasma were analyzed by gas chromatography. The κ statistic, Spearman's correlation, and multiple linear regression (adjusted for confounders) and ratio limits of agreement were employed to determine the relationship between plasma and dietary measurements.

Results: Low correlation and agreement were found between dietary and plasma fatty acids. Docosahexaenoic acid (β = 0.25; P < 0.001) and saturated (β = 0.19; P = 0.048) fatty acids exhibited an association for means of intake adjusted by the MSM and for confounding variables. A large mean difference, with a large variation of "ratio limits," were observed between the measurements.

Conclusion: Plasma and dietary polyunsaturated and saturated fatty acids exhibited low correlation and agreement, as well as weak association between each other. No association between intake and plasma concentrations of monounsaturated fat was found. Plasma fatty acids are not good biomarkers of food intake.
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http://dx.doi.org/10.1016/j.nut.2018.08.008DOI Listing
March 2019

Oxidized and electronegative low-density lipoprotein as potential biomarkers of cardiovascular risk in obese adolescents.

Clinics (Sao Paulo) 2018 10 18;73:e189. Epub 2018 Oct 18.

Departamento de Nutricao, Faculdade de Saude Publica da Universidade de Sao Paulo, Sao Paulo, SP, BR.

Objectives: To evaluate biomarkers associated with early cardiometabolic risk in obese adolescents.

Methods: This cross-sectional study included 137 adolescents of both sexes aged 10 to 19 years divided into a normal weight group (NW) (n=69) and an obese group (OB) (n=68).

Results: As expected, obesity showed positive associations with homeostatic model assessment for insulin resistance (HOMA-IR), triacylglycerol, insulin, plasma levels of non-esterified fatty acids, and cholesterol ester transfer protein activity and negative associations with plasma antioxidant levels. Plasma oxidized low-density lipoprotein (oxLDL) and electronegative low-density lipoprotein [LDL(-)] levels were significantly higher in the OB group. Higher tertiles of oxLDL were associated with increased values of body mass index; waist circumference; fatty mass percentage (%FM); and the atherogenic lipids non-high-density-lipoprotein cholesterol (non-HDL-C), low-density lipoprotein cholesterol (LDL-C), apolipoprotein B and triacylglycerol. Higher tertiles of LDL(-) were robustly associated with body mass index and waist circumference. Logistic regression models (odds ratios) confirmed that increased values of lipids and apolipoprotein B were associated with increased risk of oxLDL. For LDL(-), these associations were not significant, suggesting that another mechanism is involved in generating this particle in obese adolescents.

Conclusions: Obese adolescents showed increased plasma LDL(-) and oxLDL, and obese girls had more LDL(-) than obese boys. Therefore, oxLDL is strongly and independently associated with classical cardiovascular risk factors, while increased levels of LDL(-) were influenced by body mass index, waist circumference and demographic parameters in obese adolescents.
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http://dx.doi.org/10.6061/clinics/2018/e189DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6172975PMC
October 2018

Is Lipid Accumulation Product Associated with an Atherogenic Lipoprotein Profile in Brazilian Subjects?

Arq Bras Cardiol 2018 Apr;110(4):339-347

Faculdade de Saúde Publica, Universidade de São Paulo, São Paulo, SP, Brazil.

Background: Lipid accumulation product (LAP), a simple and low-cost tool, is a novel biomarker of central lipid accumulation and represents a potential surrogate marker for atherogenic lipoprotein profile. However, its association with lipoprotein subfractions has not been described in the literature.

Objective: To determine whether LAP index could be used as a marker of low- and high-density lipoprotein (LDL and HDL) size in Brazilian individuals.

Methods: This cross-sectional study included patients (n = 351) of both sexes and age between 30-74 years. Clinical and sociodemographic data and family history of diseases were evaluated. Lipoprotein size, and levels of total cholesterol (TC), lipoproteins, apolipoprotein AI and B (APO AI/APO B), glucose, insulin, insulin resistance index (HOMA-IR) and non-esterified fatty acids (NEFA) were assessed in blood samples. LAP was calculated by the formulas [(waist circumference[cm]-58) × (triglycerides[mmol/L]) for women and (waist circumference [cm]-65) × (triglycerides [mmol/L]) for men]. The association between LAP and metabolic parameters were tested by linear trend (general linear model, GLM test) before and after multiple adjustments for potential confounders (sex, age, smoking, statin, fibrate, and hypoglycemic drugs) at significant level p < 0.05.

Results: LAP was positively associated with TC, APO B, NEFA, glucose, insulin and HOMA-IR values, and negatively associated with HDL-C. Higher central lipid accumulation was corelated with higher percentage of intermediate HDL and of small LDL and HDL and less amount of large HDL. LDL size was also reduced in greater LAP index values. The negative impact of LAP was maintained after adjustment for multiple variables.

Conclusion: LAP was robustly associated with atherogenic profile of lipoprotein subfractions, independently of multiple confounders.
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http://dx.doi.org/10.5935/abc.20180054DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5941956PMC
April 2018

Influence of IL1B, IL6 and IL10 gene variants and plasma fatty acid interaction on metabolic syndrome risk in a cross-sectional population-based study.

Clin Nutr 2018 04 17;37(2):659-666. Epub 2017 Feb 17.

Department of Nutrition, School of Public Health, University of Sao Paulo, Dr. Arnaldo Avenue 715, São Paulo 01246-904, Brazil. Electronic address:

Background & Aims: Metabolic syndrome (MetS) is a cluster of interrelated risk factors for type 2 diabetes mellitus, and cardiovascular disease, with underlying inflammatory pathophysiology. Genetic variations and diet are well-known risk factor for MetS, but the interaction between these two factors is less explored. The aim of the study was to evaluate the influence of interaction between SNP of inflammatory genes (encoding interleukin (IL)-6, IL-1β and IL-10) and plasma fatty acids on the odds of MetS, in a population-based cross-sectional study.

Methods: Among participants of the Health Survey - São Paulo, 301 adults (19-59 y) from whom a blood sample was collected were included. Individuals with and without MetS were compared according to their plasma inflammatory biomarkers, fatty acid profile, and genotype frequency of the IL1B (rs16944, rs1143623, rs1143627, rs1143634 and rs1143643), IL6 (rs1800795, rs1800796 and rs1800797) and IL10 (rs1554286, rs1800871, rs1800872, rs1800890 and rs3024490) genes SNP. The influence of gene-fatty acids interaction on MetS risk was investigated.

Results: IL6 gene SNP rs1800795 G allele was associated with higher odds for MetS (OR = 1.88; p = 0.017). Gene-fatty acid interaction was found between the IL1B gene SNP rs116944 and stearic acid (p inter = 0.043), and between rs1143634 and EPA (p inter = 0.017). For the IL10 gene SNP rs1800896, an interaction was found for arachidonic acid (p inter = 0.007) and estimated D5D activity (p inter = 0.019).

Conclusion: The IL6 gene SNP rs1800795 G allele is associated with increased odds for MetS. Plasma fatty acid profile interacts with the IL1B and IL10 gene variants to modulate the odds for MetS. This and other interactions of risk factors can account for the unexplained heritability of MetS, and their elucidation can lead to new strategies for genome-customized prevention of MetS.
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http://dx.doi.org/10.1016/j.clnu.2017.02.009DOI Listing
April 2018

The benefits of ω-3 supplementation depend on adiponectin basal level and adiponectin increase after the supplementation: A randomized clinical trial.

Nutrition 2017 Feb 13;34:7-13. Epub 2016 Sep 13.

Department of Nutrition, Faculdade de Saúde Pública, Universidade de São Paulo, São Paulo, Brazil. Electronic address:

Objective: The aim of this study was to analyze whether ω-3 supplementation improves cardiometabolic profile in individuals with cardiovascular risk factors and to determine the effect of adiponectin levels on these changes.

Methods: In this double-blind, placebo-controlled, 2-mo clinical trial, we randomized 80 individuals of both sexes (mean age 52 y) with at least one cardiovascular risk factor (excess weight, hypertension, dyslipidemia, diabetes, or smoking) into two groups: ω-3 (supplemented with 3 g/d of fish oil containing 37% eicosapentaenoic acid and 23% docosahexaenoic acid) and placebo (3 g/d of sunflower oil containing 65% linoleic acid). At baseline and after the intervention, we evaluated serum adiponectin, leptin, lipid profile, apolipoproteins (apo), electronegative low-density lipoprotein (LDL[-]), and glucose metabolism (glucose and insulin).

Results: After supplementation, the ω-3 group showed an increase in serum adiponectin. After stratifying the ω-3 group by adiponectin concentration at baseline, participants with lower adiponectin concentration showed a higher reduction of total cholesterol, LDL, LDL/high-density lipoprotein ratio, LDL/apo B, and LDL(-). Individuals with a higher variation of adiponectin concentration after ω-3 supplementation presented with reduced blood glucose. The variation of serum adiponectin induced by ω-3 supplementation was negatively correlated with the Framingham and Adult Treatment Panel IV scores (r = -0.4 and P < 0.05 for both).

Conclusions: Adiponectin is shown as one of the mechanisms by which ω-3 improves cardiometabolic profile in persons with cardiovascular risk. Moreover, the benefit varies according to the adiponectin basal level and adiponectin variation after supplementation.
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http://dx.doi.org/10.1016/j.nut.2016.08.010DOI Listing
February 2017

Association of the conicity index with diabetes and hypertension in Brazilian women.

Arch Endocrinol Metab 2016 Oct 25;60(5):436-442. Epub 2016 Aug 25.

Departamento de Nutrição, Faculdade de Saúde Pública, Universidade de São Paulo (FSP/USP), São Paulo, SP, Brasil.

Objective: The goal of this study was evaluate the conicity index (C index) in women and its association with hypertension (SAH) and diabetes mellitus (DM).

Subjects And Methods: This was a cross-sectional study, with 573 women between 20 and 59 years of age. After analysis of clinical and demographic characteristics, anthropometric variables were measured and used to calculate the C index. Plasma glucose and lipid profile were evaluated by standard methods. The analysis of the results was based on logistic regression and the odds ratio (OR) was calculated, which was used to assess the association of the variable outcome with the variable exposure using two logistic regression models that tested the possible influence of the C index in the chance of developing SAH or DM. A confidence interval of 95% was used.

Results: In the crude and adjusted models, the OR confirmed the association of the C index with DM and SAH. Compared with women that showed C index p < 75, the risk of women with C index (p ≥ 75) developing DM and SAH was 1.72 and 1.75, respectively. Results demonstrated that the negative impact of age on these associations significantly raised the odds of women having DM and SAH. The high C index was also linked to low HDL-C.

Conclusion: The C index is an important tool in estimating the risk of diabetes and hypertension in women. Besides, high C indexes are negatively associated with HDL-C, an important lipid marker related to cardiovascular risk.
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http://dx.doi.org/10.1590/2359-3997000000187DOI Listing
October 2016

Effect of classic ketogenic diet treatment on lipoprotein subfractions in children and adolescents with refractory epilepsy.

Nutrition 2017 Jan 26;33:271-277. Epub 2016 Jul 26.

Department of Nutrition, School of Public Health, University of Sao Paulo, Sao Paulo, Brazil. Electronic address:

Objective: The aim of this study was to evaluate the effects of the classic ketogenic diet (KD) on low-density lipoprotein (LDL) and high-density lipoprotein (HDL) subfractions in children and adolescents with refractory epilepsy.

Methods: This prospective study recruited children and adolescents of either sex, whose epilepsy was refractory to treatment with multiple drugs. To be included, the patient had to have an indication for treatment with the KD and be treated as an outpatient. At baseline and after 3 and 6 mo of the KD, lipid profile (total cholesterol [TC], triacylglycerols [TG], LDL cholesterol [LDL-C], and HDL cholesterol [HDL-C]), apolipoproteins (apoA-I and apoB), 10 subfractions of HDL, 7 subfractions of LDL, LDL phenotype, and LDL size were analyzed using the Lipoprint system.

Results: The lipid profile components (TC, TG, LDL-C, HDL-C, apoA-I, and apoB) increased during the 3-mo follow-up, and remained consistent after 6 mo of treatment. Similarly, non-HDL-C, TC/HDL-C, LDL-C/HDL-C, and apoB/apoA-I ratios, representing atherogenic particles, significantly increased. In contrast, qualitative lipoprotein characteristics progressively changed during the follow-up period. Small LDL subfractions increased, and this profile was related with reduced LDL size (27.3 nm to 26.7 nm). The LDL phenotype became worse; 52.1% of the patients had a non-A phenotype after 6 mo of the KD. Small HDL subfractions decreased only after 6 mo of the KD.

Conclusions: KD treatment promotes negative changes in lipoprotein size and phenotype, contributing to atherogenic risk in these patients.
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http://dx.doi.org/10.1016/j.nut.2016.06.016DOI Listing
January 2017

Influence of adiponectin gene variants and plasma fatty acids on systemic inflammation state association-A cross-sectional population-based study, São Paulo, Brazil.

Mol Nutr Food Res 2016 Feb 20;60(2):278-86. Epub 2015 Oct 20.

Nutrition Department, School of Public Health of University of São Paulo, Brazil.

Scope: Interactions between adiponectin genetic variants and plasma fatty acid profile can modulate plasma inflammatory biomarker concentration and the risk for metabolic diseases. The aim of this study was to investigate the interaction between single nucleotide polymorphisms of the adiponectin gene and plasma fatty acid profile in modulating the odds for systemic inflammation in a cross-sectional population-based study.

Methods And Results: Inflammatory patterns comprised 11 inflammatory biomarkers. Among participants of the Health Survey of São Paulo, 262 adults (19-59 years) met the inclusion criteria. Anthropometric parameters, blood pressure, plasma inflammatory biomarker concentration, and fatty acid profile were measured and five single nucleotide polymorphisms of the adiponectin gene (rs2241766, rs1501299, rs16861209, rs17300539, and rs266729) genotyped. Individuals in the upper 50th percentile for plasma araquidonic acid, n-3 highly unsaturated fatty acid and estimated delta-5-desaturase activity, had reduced odds of being in the inflammatory cluster (OR (95% CI) = 0.55 (0.32-0.95), 0.50 (0.28-0.88) and 0.48 (0.28-0.83), respectively). Gene-plasma fatty acid profile interaction was found between rs2241766 and n-3 (p = 0.019), rs16861209 and araquidonic acid and docosapentaenoic acid (p = 0.044, p = 0.037, respectively), and rs17300539 and saturated fatty acid (p = 0.019).

Conclusion: Plasma fatty acid profile can interact with adiponectin gene variants to modulate the risk for systemic inflammatory state.
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http://dx.doi.org/10.1002/mnfr.201500527DOI Listing
February 2016

NUTRITION THERAPY IN SEPSIS: CHARACTERIZATION AND IMPLICATIONS FOR CLINICAL PROGNOSIS.

Nutr Hosp 2015 Sep 1;32(3):1281-8. Epub 2015 Sep 1.

Head of Adult Intensive Care Unit in HUUSP. Professor, School of Medicine -USP -SP. Research place University Hospital (HU), University of São Paulo - USP - São Paulo SP (Brazil)..

Introduction: the inflammatory response caused by sepsis leads to metabolic changes, which may result in significant lean mass loss in septic patient. Because of this, when digestive tract is functional, nutritional therapy (NT) must be initiated within 48 hours of intensive treatment to reduce protein loss.

Objective: to evaluate enteral nutritional therapy (ENT) in adult septic patients with exclusive ENT for ≥ 72 hours and length of stay ≥7 days in Intensive Care Unit and its relationship with clinical prognosis.

Methods: we prospectively analyzed the adequacy of enteral nutrition administered, factors associated with non-conformity, gastrointestinal tolerance and outcome. Statistical tests of chi-square and Student's t as well as Mann-Whitney and Spearman and Pearson correlations (p < 0.05) were used. A multiple logistic regression model has been done by using the stepwise method to evaluate the association between predictors of clinical outcome.

Results: 53 patients, 67.9% male and 52.8% elderly were enrolled in this study. The average time for starting ENT was 30 (23.5) hours, and 88.7% of patients achieved nutritional goal in 48 hours. The mean volume delivered in relation to prescribed was 78.9%. When the sample was stratified according to administered/ prescribed calories, patients who received < 80% had a higher mortality rate (p = 0.001) and the caloric intake ≥ 80% was the determining factor in patients' clinical prognosis (p = 0.021).

Conclusion: septic patients received early enteral nutrition. The nutritional goal and the mean volume delivered in relation to the prescribed volume meet the intensive care guidelines. The nutritional support was associated with clinical outcome, and caloric intake ≥ 80% determining the clinical prognosis. The pauses caused by reflux were significant in the group of patients who died and it may be related to disease severity.
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http://dx.doi.org/10.3305/nh.2015.32.3.9266DOI Listing
September 2015

FISH OIL AND VITAMIN E CHANGE LIPID PROFILES AND ANTI-LDL-ANTIBODIES IN TWO DIFFERENT ETHNIC GROUPS OF WOMEN TRANSITIONING THROUGH MENOPAUSE.

Nutr Hosp 2015 Jul 1;32(1):165-74. Epub 2015 Jul 1.

Department of Nutrition. School of Public Health. University of São Paulo (USP)..

Background: studies have investigated the relationship between the transition through menopause and cardiovascular diseases. White population, generally, have lower levels of traditional coronary heart risk factors, particularly dyslipidemia, hypertension, obesity, and diabetes, and lower rates of coronary heart disease mortality, than black population. Furthermore many studies have shown the cardioprotective and anti-inflammatory effects of omega-3 polyunsaturated fatty acids (eicosapentaenoic acid and docosahexaenoic acid) of marine origin. The aim of this study was to investigate the effect of omega-3 supplementation, combined or not with vitamin E, on oxidative biomarkers and lipid profiles in nonwhite and white women with dyslipidemia transitioning through menopause.

Methods: a randomized, double-blind, placebo-controlled trial was conducted. Seventy-four eligible women were assigned to receive: fish oil, fish oil plus vitamin E and placebo for three months. At baseline, 45 and 90 days blood sample for biochemical variables and biomarkers of oxidative stress were taken. Socioeconomic and lifestyle variables were collected with standardized questionnaires.

Results: after 90 days the fish oil plus vitamin E treated group had a significant decrease in total cholesterol and LDL-C. Furthermore, there was a decrease in anti- LDL- autoantibodies after 45 days. Plasma TBARS concentrations were increased after 90 days in the group receiving only fish oil when compared to the placebo and fish oil-vitamin E groups. All of the effects observed were independent of ethnic group.

Conclusion: supplementation with fish oil and vitamin E reduced total cholesterol and LDL-C, but had opposite effects on oxidative stress compared to supplementation with fish oil alone.
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http://dx.doi.org/10.3305/nh.2015.32.1.9079DOI Listing
July 2015

Ketogenic diet in epileptic children: impact on lipoproteins and oxidative stress.

Nutr Neurosci 2015 15;18(8):337-44. Epub 2015 Jul 15.

Objectives: Ketogenic diet (KD) is an important therapy used in the control of drug-refractory seizures. The major goal of this review is to update the knowledge about the adverse effects of KD on lipoproteins, lipid profile, and cardiometabolic risk.

Methods: Articles on the effect of the KD on plasma lipoproteins of children and adolescents with refractory epilepsy, which were published in the past 15 years and indexed in the PubMed and MedLine databases, were included.

Results: Dyslipidemia was recurrent in children, and adolescents treated with KD. Evidence suggests that hypercholesterolemia promotes structural modifications in low-density lipoprotein particles. Such modifications possibly favor oxidative processes and contribute to changes in the size of lipoproteins, particularly related to small and denser LDL. However, oxidative modifications in LDL of children on KD are not described in the literature.

Discussion: The positive effects of KD on the health of children and adolescents with refractory epilepsy are unquestionable. Conversely, this positive role is associated with significant and negative changes in lipid metabolism. Moreover, the positive effects are possibly related to oxidative reactions and unbalance of antioxidants that can contribute to an increased cardiometabolic risk. Therefore, this review invites clinicians and researchers to investigate the lipid and oxidative metabolism in their clinical practice and trials, respectively.
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http://dx.doi.org/10.1179/1476830515Y.0000000036DOI Listing
September 2016

Effect of chemotherapy on dietary glycemic index and load in patients with breast cancer and their relationships to body fat and phase angle.

Nutr Cancer 2015 14;67(4):587-93. Epub 2015 Apr 14.

a Department of Nutrition , School of Public Health, University of São Paulo , São Paulo , Brazil.

Dietary glycemic index (GI) and glycemic load (GL) are indicators of carbohydrate consumption and widely used in studies evaluating the risk for breast cancer. However, the effect of chemotherapy on these indices has been scarcely studied. The aim of this study was to evaluate dietary levels of GI and GL in women with breast cancer during chemotherapy treatment and their relationships to body fat and phase angle. Twenty-five patients were assessed according to demographic, clinical, anthropometric, and food consumption data. Dietary intake was assessed by 24-h dietary recalls applied on nonconsecutive days. Anthropometric measures and body composition were determined at all study timepoints: prior to the first chemotherapy cycle (T0), immediately after the last chemotherapy cycle (T1), and 2 months after T1 (T2). There was no difference in mean GI and GL among study timepoints. However, a high prevalence of inadequate GI and GL values was noted, independent of study timepoint. GI and GL were associated with phase angle at T1. GI was associated with percentage fat at T0 only. Dietary GI and GL were unchanged during chemotherapy, but were associated with indicators of clinical outcome, such as percentage fat and phase angle.
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http://dx.doi.org/10.1080/01635581.2015.1019638DOI Listing
February 2016

Neurobiochemical mechanisms of a ketogenic diet in refractory epilepsy.

Clinics (Sao Paulo) 2014 Dec;69(10):699-705

Department of Nutrition, School of Public Health, Universidade de São Paulo, São Paulo, SP, Brazil.

A ketogenic diet is an important therapy used in the control of drug-refractory seizures. Many studies have shown that children and adolescents following ketogenic diets exhibit an over 50% reduction in seizure frequency, which is considered to be clinically relevant. These benefits are based on a diet containing high fat (approximately 90% fat) for 24 months. This dietary model was proposed in the 1920s and has produced variable clinical responses. Previous studies have shown that the mechanisms underlying seizure control involve ketone bodies, which are produced by fatty acid oxidation. Although the pathways involved in the ketogenic diet are not entirely clear, the main effects of the production of ketone bodies appear to be neurotransmitter modulation and antioxidant effects on the brain. This review highlights the impacts of the ketogenic diet on the modulation of neurotransmitters, levels of biogenic monoamines and protective antioxidant mechanisms of neurons. In addition, future perspectives are proposed.
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http://dx.doi.org/10.6061/clinics/2014(10)09DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4221309PMC
December 2014

[Old and new anthropometric indices as insulin resistance predictors in adolescents].

Arq Bras Endocrinol Metabol 2014 Nov 1;58(8):838-43. Epub 2014 Nov 1.

Faculdade de Saúde Pública, Universidade de São Paulo, São Paulo, SP, Brasil.

Objective: Despite the importance of insulin resistance (IR) on chronic diseases development, its diagnosis remains invasive. Thus, it's necessary to develop alternative methods to predict IR on clinical practice, and the anthropometric indices are a good alternative to it. Given that, this study's purpose is to evaluate these indices behavior in relation to HOMA-IR (Homeostasis Model Assessment of Insulin Resistance).

Materials And Methods: We collected weight, height and waist circumference from 148 adolescents. Through these indices, we calculated the body mass index (BMI), inverted body mass index (iBMI), waist-to-height ratio (WHtR) and conicity index (C index). We also collected data from body composition (body fat percentage - %BF), through electric impedance, and biochemical data (fasting glucose and insulin levels) employed on the HOMA-IR calculation. The HOMA-IR cutoff adopted was of 2.39±1.93. The statistical analysis involved the Spearman correlation analysis, multiple linear regression models and ROC (Receiver Operating Characteristic) curves construction, using 95% CI. We used the statistic pack SPSS v.18, considering p<0.05 as the significance level.

Results: All anthropometric indices were statistically and positively correlated to HOMA-IR. The ROC curve showed that WC, WHtR and C index, in this order, were the most efficient to predict IR.

Conclusion: Among the indicators studied, those related to central fat accumulation seem the most suitable for predicting IR.
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http://dx.doi.org/10.1590/0004-2730000003296DOI Listing
November 2014

Adequacy of energy and protein balance of enteral nutrition in intensive care: what are the limiting factors?

Rev Bras Ter Intensiva 2014 Apr-Jun;26(2):155-62

Unidade de Terapia Intensiva Adulto, Hospital Universitário, Universidade de São Paulo, São Paulo, SP, Brasil.

Objective: To determine the factors that influence the adequacy of enteral nutritional therapy in an intensive care unit.

Methods: This prospective observational study was conducted in an intensive care unit between 2010 and 2012. Patients >18 years of age underwent exclusive enteral nutritional therapy for ≥72 hours. The energy and protein requirements were calculated according to the ICU protocols. The data regarding enteral nutrition, the causes of non-compliance, and the biochemical test results were collected daily.

Results: Ninety-three patients admitted to the intensive care unit were evaluated. Among these patients, 82% underwent early enteral nutritional therapy, and 80% reached the nutritional goal in <36 hours. In addition, 81.6%±15.4% of the enteral nutrition volume was infused, with an adequacy of 82.2%±16.0% for calories, 82.2%±15.9% for proteins, and a mean energy balance of -289.9±277.1 kcal/day. A negative correlation of C-reactive protein with the volume infused and the energy and protein balance was observed. In contrast, a positive correlation was found between C-reactive protein and the time required to reach nutritional goals. Extubation was the main cause for interrupting the enteral nutritional therapy (29.9% of the interruption hours), and the patients >60 years of age exhibited a lower percentage of recovery of the oral route compared with the younger patients (p=0.014).

Conclusion: Early enteral nutritional therapy and the adequacy for both energy and protein of the nutritional volume infused were in accordance with the established guidelines. Possible inadequacies of energy and protein balance appeared to be associated with an acute inflammatory response, which was characterized by elevated C-reactive protein levels. The main cause of interruption of the enteral nutritional therapy was the time spent in extubation.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4103942PMC
http://dx.doi.org/10.5935/0103-507x.20140023DOI Listing
August 2015

Effects of two lipid lowering therapies on immune responses in hyperlipidemic subjects.

Life Sci 2014 Mar 18;98(2):83-7. Epub 2014 Jan 18.

Department of Medicine, Federal University of São Paulo, Sao Paulo, SP, Brazil. Electronic address:

Aims: To compare the effects of two of the most effective lipid-lowering therapies with similar LDL-cholesterol reduction capacity on the innate and adaptive immune responses through the evaluation of autoantibodies anti-oxidized LDL (anti-oxLDL Abs) and electronegative LDL [LDL(-)] levels.

Main Methods: We performed a prospective, randomized, open label study, with parallel arms and blinded endpoints. One hundred and twelve subjects completed the study protocol and received rosuvastatin 40 mg or ezetimibe/simvastatin 10/40 mg for 12 weeks. Lipids, apolipoproteins, LDL(-), and anti-oxLDL Abs (IgG) were assayed at baseline and end of study.

Key Findings: Main clinical and laboratory characteristics were comparable at baseline. Lipid modifications were similar in both treatment arms, however, a significant raise in anti-oxLDL Abs levels was observed in subjects treated with rosuvastatin (p=0.026 vs. baseline), but not in those receiving simvastatin/ezetimibe. (p=0.233 vs. baseline), thus suggesting modulation of adaptive immunity by a potent statin. Titers of LDL(-) were not modified by the treatments.

Significance: Considering atherosclerosis as an immune disease, this study adds new information, showing that under similar LDL-cholesterol reduction, the choice of lipid-lowering therapy can differently modulate adaptive immune responses.
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http://dx.doi.org/10.1016/j.lfs.2014.01.001DOI Listing
March 2014

Is plasma alpha-tocopherol associated with electronegative LDL in obese adolescents?

J Nutr Sci Vitaminol (Tokyo) 2013 ;59(2):100-7

Department of Nutrition, School of Public Health, University of São Paulo, SP, Brazil.

Obesity has increased in children and adolescents. What is reflected in the early occurrence of cardiometabolic alterations, like hypertension and type 2 diabetes, where the oxLDL formation is stimulated. Various studies have shown that plasma α-tocopherol (α-TP) can protect LDL against oxidation. Nevertheless, the action of plasma α-TP in cardiovascular diseases remains controversial. We conducted a cross-sectional study to evaluate plasma α-TP and its impact on the concentration of LDL(-). Adolescents (n=150) of both sexes were classified into three groups: healthy weight (HW; 50%), overweight (OV; 22%), and obese (OB; 28%). Lipid profile, LDL(-), anti-oxLDL and anti-LDL(-) antibodies, CRP (ELISA) and plasma α-TP (HPLC) were analyzed. Demographic, anthropometric, and food intake data were evaluated. Crude and energy-adjusted intake of vitamin E in the OB group were higher than in the HW group (p<0.001). Crude and energy-adjusted vitamin E intakes were not correlated with plasma α-TP (r=-0.07; p=0.412 and r=-0.064; p=0.467, respectively). Subjects in the OB group had higher TC and LDL-C and lower HDL-C than in the HW and OV groups. C-reactive protein and anti-oxLDL antibodies changed as a function of BMI. The impact of obesity was reinforced by high values for LDL(-) and low content of plasma α-TP in comparison with the HW (p<0.001) and OV groups (p=0.03). This negative profile was maintained for the ratio between α-TP and TC or LDL-C. Plasma α-TP, α-TP/TC and α-TP/LDL-C were negatively associated with LDL(-) and other cardiometabolic risk factors (BMI, WC, AC and anti-oxLDL). Our results demonstrate that obesity in adolescents is associated with high levels of LDL(-) and low plasma α-TP content.
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http://dx.doi.org/10.3177/jnsv.59.100DOI Listing
January 2014
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