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India Aldana S, Colicino E, Cantoral Preciado A, Tolentino M, Baccarelli AA, Wright RO, Téllez Rojo MM, Valvi D. Longitudinal associations between early-life fluoride exposures and cardiometabolic outcomes in school-aged children. ENVIRONMENT INTERNATIONAL 2024; 183:108375. [PMID: 38128386 PMCID: PMC10842303 DOI: 10.1016/j.envint.2023.108375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 11/06/2023] [Accepted: 12/06/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND/AIM Fluoride is a natural mineral present in food, water, and dental products, constituting ubiquitous long-term exposure in early childhood and across the lifespan. Experimental evidence shows fluoride-induced lipid disturbances with potential implications for cardiometabolic health. However, epidemiological studies are scarce. For the first time, we evaluated associations between repeated fluoride measures and cardiometabolic outcomes in children. METHODS We studied ∼ 500 Mexican children from the Programming Research in Obesity, Growth, Environment and Social Stressors (PROGRESS) cohort with measurements on urinary fluoride at age 4, and dietary fluoride at ages 4, 6, and 8 years approximately. We used covariate-adjusted linear mixed-effects and linear regression models to assess fluoride associations with multiple cardiometabolic outcomes (ages 4-8): lipids (total cholesterol, HDL, LDL, and triglycerides), glucose, HbA1c, adipokines (leptin and adiponectin), body fat, and age- and sex-specific z-scores of body mass index (zBMI), waist circumference, and blood pressure. RESULTS Dietary fluoride intake at age 4 was associated with annual increases in triglycerides [β per-fluoride-doubling = 2.02 (95 % CI: 0.37, 3.69)], cholesterol [β = 1.46 (95 % CI: 0.52, 2.39)], HDL [β = 0.39 (95 % CI: 0.02, 0.76)], LDL [β = 0.87 (95 % CI: 0.02, 1.71)], and HbA1c [β = 0.76 (95 % CI: 0.28, 1.24)], and decreased leptin [β = -3.58 (95 % CI: -6.34, -0.75)] between the ages 4 and 8. In cross-sectional analyses at age 8, higher tertiles of fluoride exposure were associated with increases in zBMI, triglycerides, glucose, and leptin (p-tertile trend < 0.05). Stronger associations were observed in boys at year 8 and in girls prior to year 8 (p-sex interaction < 0.05). Fewer but consistent associations were observed for urinary fluoride at age 4, indicating increased annual changes in HDL and HbA1c with higher fluoride levels. CONCLUSION Dietary fluoride exposures in early- and mid-childhood were associated with adverse cardiometabolic outcomes in school-aged children. Further research is needed to elucidate whether these associations persist at later ages.
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Affiliation(s)
- Sandra India Aldana
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Elena Colicino
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Maricruz Tolentino
- Department of Nutrition, National Institute of Perinatology, Mexico City, Mexico
| | - Andrea A Baccarelli
- Departments of Environmental Health Sciences and Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Robert O Wright
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Martha María Téllez Rojo
- Center for Nutrition and Health Research, National Institute of Public Health, Cuernavaca, Morelos, Mexico
| | - Damaskini Valvi
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Trevizol JS, Dionizio A, Delgado AQ, Ventura TMO, Ribeiro CFDS, Ribeiro L, Buzalaf NR, Cestari TM, Magalhães AC, Suzuki M, Bosqueiro JR, Buzalaf MAR. Metabolic effect of low fluoride levels in the islets of NOD mice: integrative morphological, immunohistochemical, and proteomic analyses. J Appl Oral Sci 2023; 31:e20230036. [PMID: 37283331 PMCID: PMC10247282 DOI: 10.1590/1678-7757-2023-0036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 03/31/2023] [Accepted: 05/03/2023] [Indexed: 06/08/2023] Open
Abstract
OBJECTIVES Fluoride (F) has been widely used to control dental caries, and studies suggest beneficial effects against diabetes when a low dose of F is added to the drinking water (10 mgF/L). This study evaluated metabolic changes in pancreatic islets of NOD mice exposed to low doses of F and the main pathways altered by the treatment. METHODOLOGY In total, 42 female NOD mice were randomly divided into two groups, considering the concentration of F administered in the drinking water for 14 weeks: 0 or 10 mgF/L. After the experimental period, the pancreas was collected for morphological and immunohistochemical analysis, and the islets for proteomic analysis. RESULTS In the morphological and immunohistochemical analysis, no significant differences were found in the percentage of cells labelled for insulin, glucagon, and acetylated histone H3, although the treated group had higher percentages than the control group. Moreover, no significant differences were found for the mean percentages of pancreatic areas occupied by islets and for the pancreatic inflammatory infiltrate between the control and treated groups. Proteomic analysis showed large increases in histones H3 and, to a lesser extent, in histone acetyltransferases, concomitant with a decrease in enzymes involved in the formation of acetyl-CoA, besides many changes in proteins involved in several metabolic pathways, especially energy metabolism. The conjunction analysis of these data showed an attempt by the organism to maintain protein synthesis in the islets, even with the dramatic changes in energy metabolism. CONCLUSION Our data suggests epigenetic alterations in the islets of NOD mice exposed to F levels comparable to those found in public supply water consumed by humans.
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Affiliation(s)
- Juliana Sanches Trevizol
- Universidade de São Paulo, Faculdade de Odontologia de Bauru, Departamento de Ciências Biológicas, Bauru, SP, Brasil
| | - Aline Dionizio
- Universidade de São Paulo, Faculdade de Odontologia de Bauru, Departamento de Ciências Biológicas, Bauru, SP, Brasil
| | | | | | | | - Laura Ribeiro
- Universidade de São Paulo, Faculdade de Odontologia de Bauru, Departamento de Ciências Biológicas, Bauru, SP, Brasil
| | - Nathalia Rabelo Buzalaf
- Universidade de São Paulo, Faculdade de Odontologia de Bauru, Departamento de Ciências Biológicas, Bauru, SP, Brasil
| | - Tânia Mary Cestari
- Universidade de São Paulo, Faculdade de Odontologia de Bauru, Departamento de Ciências Biológicas, Bauru, SP, Brasil
| | - Ana Carolina Magalhães
- Universidade de São Paulo, Faculdade de Odontologia de Bauru, Departamento de Ciências Biológicas, Bauru, SP, Brasil
| | - Maiko Suzuki
- The Dental College of Georgia, Department of Oral Biology and Diagnostic Sciences, Augusta, Georgia, United States
| | - José Roberto Bosqueiro
- Universidade Estadual Paulista, Faculdade de Ciências, Departamento de Educação Física, Bauru, São Paulo, Brasil
| | - Marília Afonso Rabelo Buzalaf
- Universidade de São Paulo, Faculdade de Odontologia de Bauru, Departamento de Ciências Biológicas, Bauru, SP, Brasil
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Dong S, Yang Y, He B, Xu Z, Zhou Z, Wang J, Chen C, Chen Q. Effect of Sodium Fluoride on Reproductive Function Through Regulating Reproductive Hormone Level and Circulating SIRT1 in Female Rats. Biol Trace Elem Res 2023; 201:1825-1836. [DOI: https:/doi.org/10.1007/s12011-022-03283-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 05/04/2022] [Indexed: 02/14/2024]
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Dong S, Yang Y, He B, Xu Z, Zhou Z, Wang J, Chen C, Chen Q. Effect of Sodium Fluoride on Reproductive Function Through Regulating Reproductive Hormone Level and Circulating SIRT1 in Female Rats. Biol Trace Elem Res 2023; 201:1825-1836. [PMID: 35538195 DOI: 10.1007/s12011-022-03283-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 05/04/2022] [Indexed: 11/02/2022]
Abstract
Fluorosis causes female reproductive dysfunction with reduced fertility without established pathogenesis. To clarify the mechanism, Sprague-Dawley female rats were selected with drinking water containing 0, 50 (low), 100 (moderate), and 150 mg/L (high) sodium fluoride (NaF) for a short (2 months), medium (4 months), and long term (6 months). The water consumption and body weight of female rats were recorded daily. The effect of NaF on the estrous cycle was examined by vaginal smears and recorded in different term treatments. Female and male rats were mated in a 2:1 ratio for 1 week at 2-, 4-, and 6-month treatment time for mating performance and fertility rate. Selected female rats were executed for tissue and blood collection at different treatment terms. Twenty-four-hour urine sample from each female rat was collected using the metabolic cage. The levels of steroid hormones and silent information regulator 2 homolog 1 (SIRT1) in serum were measured by appropriate ELISA kits. Body weight of the high NaF group was significantly less during short-term treatment than that of other treatment groups or control group. Urinary fluoride concentration was increased linearly with treatment time. Treatment of NaF significantly decreased steroid hormone level while increased SIRT1 level in the serum. In addition, NaF treatment significantly decreased pregnancy rate. It is concluded that NaF inhibits the secretion of hormone and estradiol (E2) release from the ovary, thereby reducing the rate of pregnant. SIRT1 may be involved in this NaF-induced reproductive dysfunction in female rats through regulating reproductive hormone, FSH, and LH secretion.
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Affiliation(s)
- Siyuan Dong
- Guipei Class s0141, Xi'an Jiaotong University Health Science Center, Xi'an Jiaotong University, Xi'an, Shaanxi, 710061, People's Republic of China
| | - Yanni Yang
- Xianyang Central Hospital, Xianyang, People's Republic of China
| | - Biqi He
- Class 0128#, Xi'an Jiaotong University Health Science Center, Xi'an Jiaotong University, Xi'an, Shaanxi, 710061, People's Republic of China
| | - Zhao Xu
- School of Chemistry, Xi'an Jiaotong University, Xi'an, People's Republic of China
| | | | - Jinhai Wang
- Department of Gastroenterology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an Jiaotong University, Xi'an, Shaanxi, 710061, People's Republic of China
| | - Chen Chen
- Endocrinology, School of Biomedical Sciences, Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Qun Chen
- Institute of Endemic Diseases, Key Laboratory of Trace Elements and Endemic Diseases, National Health and Family Planning Commission of the People's Republic of China, Key Laboratory for Disease Prevention and Control and Health Promotion of Shaanxi Province, Xi'an Jiaotong University Health Science Center, No. 76, Yanta Western Road, Shaanxi, 710061, Xi'an, People's Republic of China.
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Zhou G, Li Q, Hou X, Wu H, Fu X, Wang G, Ma J, Cheng X, Yang Y, Chen R, Li Z, Yu F, Zhu J, Ba Y. Integrated 16S rDNA sequencing and metabolomics to explore the intestinal changes in children and rats with dental fluorosis. ECOTOXICOLOGY AND ENVIRONMENTAL SAFETY 2023; 251:114518. [PMID: 36640576 DOI: 10.1016/j.ecoenv.2023.114518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 12/19/2022] [Accepted: 01/05/2023] [Indexed: 06/17/2023]
Abstract
Dental fluorosis (DF) is a widely prevalent disease caused by excessive fluoride with limited awareness of its underlying pathogenesis. Here, a pilot population study was conducted to explore the pathogenesis of DF from the perspective of intestinal microbiome changes, and verified it in animal experiments combining intestinal microbiome and metabolomics. A total of 23 children were recruited in 2017 in China and divided into DF (n = 9) and control (n = 14) groups (DFG and CG, respectively). The SD rat model was established by drinking water containing sodium fluoride (NaF). Gut microbiome profiles of children and rats were analyzed by16S rDNA V3-V4 sequencing, and the intestinal metabolomics analysis of rats was performed by LC-MS methods. The 16 S rDNA sequencing revealed that the gut microbiome composition was significantly perturbed in children in DFG compared to that in CG. Acidobacteria and Thermi were specifically observed in DFG and CG, respectively. Besides, 15 fecal microbiotas were significantly altered at the genus level in DFG. Furthermore, only the expression of annotated genes for pentose and glucuronate interconversion pathway was significant lower in DFG than that in CG (P = 0.04). Notably, in NaF-treated rats, we also observed the changes of some key components of pentose and glucuronate interconversion pathway at the level of microorganisms and metabolites. Our findings suggested that the occurrence of DF is closely related to the alteration of intestinal microorganisms and metabolites annotated in the pentose and glucuronate interconversion pathway.
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Affiliation(s)
- Guoyu Zhou
- Department of Environment Health, School of Public Health of Zhengzhou University, Zhengzhou, Henan, PR China; Yellow River Institute for Ecological Protection & Regional Coordinated Development, Zhengzhou University, Zhengzhou, Henan, PR China; National Health Commission Key Laboratory of Birth Defects Prevention, Henan Key Laboratory of Population Defects Prevention, Zhengzhou, Henan, PR China
| | - Qingyuan Li
- Department of Environment Health, School of Public Health of Zhengzhou University, Zhengzhou, Henan, PR China
| | - Xiangbo Hou
- Department of Environment Health, School of Public Health of Zhengzhou University, Zhengzhou, Henan, PR China
| | - Huiying Wu
- Department of Environment Health, School of Public Health of Zhengzhou University, Zhengzhou, Henan, PR China
| | - Xiaoli Fu
- Department of Environment Health, School of Public Health of Zhengzhou University, Zhengzhou, Henan, PR China
| | - Guoqing Wang
- Department of Environment Health, School of Public Health of Zhengzhou University, Zhengzhou, Henan, PR China
| | - Jun Ma
- Department of Endemic Disease, Kaifeng Center for Disease Control and Prevention, Kaifeng, Henan, PR China
| | - Xuemin Cheng
- Department of Environment Health, School of Public Health of Zhengzhou University, Zhengzhou, Henan, PR China
| | - Yang Yang
- Department of Preventive Medicine, School of Public Health, Zhengzhou University, Zhengzhou, Henan, PR China
| | - Ruiqin Chen
- Jinshui District Center for Disease Control and Prevention, Zhengzhou, Henan, PR China
| | - Zhiyuan Li
- Department of Environment Health, School of Public Health of Zhengzhou University, Zhengzhou, Henan, PR China
| | - Fangfang Yu
- Department of Environment Health, School of Public Health of Zhengzhou University, Zhengzhou, Henan, PR China
| | - Jingyuan Zhu
- Department of Environment Health, School of Public Health of Zhengzhou University, Zhengzhou, Henan, PR China.
| | - Yue Ba
- Department of Environment Health, School of Public Health of Zhengzhou University, Zhengzhou, Henan, PR China; Yellow River Institute for Ecological Protection & Regional Coordinated Development, Zhengzhou University, Zhengzhou, Henan, PR China.
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Ding L, Yang Q, Sun Z, Liu L, Meng Z, Zhao X, Tao N, Liu J. Association between dietary intake of one-carbon metabolism nutrients and hyperglycemia in coal-burning fluorosis areas of Guizhou, China. Front Nutr 2022; 9:1002044. [PMID: 36299987 PMCID: PMC9589113 DOI: 10.3389/fnut.2022.1002044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 09/23/2022] [Indexed: 11/13/2022] Open
Abstract
Background and aims There are limited studies describing the association between dietary intake of one-carbon metabolism nutrients and hyperglycemia. The present study aimed to investigate the association of habitual dietary intake of one-carbon metabolism nutrients with hyperglycemia in a fluorosis area in China, and explored the interaction between these nutrients and fluorosis related to hyperglycemia. Method In a cross-sectional study, we recruited 901 villagers, ages ranging from 18–75, in Guizhou Province. Dietary data and other covariate data were obtained through an interviewer-administered questionnaire. We collected venous blood samples from participants who had fasted for one night to obtain fasting blood glucose levels and we categorized dietary intake of betaine, total choline, methionine, folate, vitamins B6 and B12, and choline subclasses into quartiles (Q1–Q4). The lowest quartile (Q1) served as the reference group. An unconditional logistic regression model was used to evaluate the protective effects of a dietary intake of one-carbon nutrients against hyperglycemia. We calculated Odds Ratios (ORs) with 95% confidence intervals (CIs). A presence or absence of fluorosis subgroup analysis was performed to determine the potential effect of fluorosis on hyperglycemia. Result After adjusting for potential confounding factors, we found that a greater intake of dietary vitamin B6, total choline and methyl-donor index was inversely associated with the occurrence of hyperglycemia (P-trend <0.05). However, there were no significant associations between hyperglycemia and the dietary intake of folate, vitamin B12, methionine, and betaine. As for the choline subgroups, it showed that the dietary intake of free choline, phosphatidylcholine, and glycerol phosphatidylcholine was negatively correlated with the occurrence of hyperglycemia (P < 0.05). In contrast, there was no statistical association between dietary phosphatidylcholine and sphingomyelin and hyperglycemia (all P > 0.05). The results of subgroup analysis showed that dietary intake of folate, vitamin B6, total choline, free choline, glycerol phosphorylcholine, and phosphocholine had a protective effect against the occurrence of hyperglycemia in the non-fluorosis subgroup, although no effects were observed in the fluorosis subgroup. There were significant interactions between these nutrients and fluorosis (P = 0.010–0.048). Conclusion The study demonstrated that higher dietary intake of vitamin B6, total choline, methyl-donor index, free choline, glycerol phosphorylcholine, and phosphocholine in choline compounds were associated with a lower incidence of hyperglycemia. Moreover, the associations were modified by the presence or absence of fluorosis. Further investigation is needed to test the association in large-scale follow-up studies.
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Affiliation(s)
- Li Ding
- Department of Preventive Medicine, School of Public Health, Zunyi Medical University, Zunyi, China,Department of Nutrition and Food Hygiene, School of Public Health, Soochow University, Suzhou, China
| | - Qinglin Yang
- Department of Preventive Medicine, School of Public Health, Zunyi Medical University, Zunyi, China
| | - Zhongming Sun
- Department of Preventive Medicine, School of Public Health, Zunyi Medical University, Zunyi, China
| | - Lu Liu
- Department of Preventive Medicine, School of Public Health, Zunyi Medical University, Zunyi, China
| | - Zeyu Meng
- Department of Preventive Medicine, School of Public Health, Zunyi Medical University, Zunyi, China
| | - Xun Zhao
- Department of Chronic Disease, Center of Disease Control and Prevention of Zhijin County, Bijie, China
| | - Na Tao
- Department of Pharmacy, Affiliated Hospital of Zunyi Medical University, Zunyi, China,*Correspondence: Na Tao
| | - Jun Liu
- Department of Preventive Medicine, School of Public Health, Zunyi Medical University, Zunyi, China,Jun Liu
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Effects of SNPs in SOD2 and SOD3 interacted with fluoride exposure on the susceptibility of dental fluorosis. Int J Hyg Environ Health 2021; 239:113879. [PMID: 34758947 DOI: 10.1016/j.ijheh.2021.113879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 10/11/2021] [Accepted: 10/28/2021] [Indexed: 11/21/2022]
Abstract
A total of 649 children aged 7-13 years of age were recruited in a cross-sectional study in Tongxu County, China (2017) to assess the effects of interaction between single nucleotide polymorphisms (SNPs) in SOD2 and SOD3 gene and fluoride exposure on dental fluorosis (DF) status. Associations between biomarkers and DF status were evaluated. Logistic regression suggested that the risk of DF in children with rs10370 GG genotype and rs5746136 TT genotype was 1.89-fold and 1.72-fold than that in children with TT/CC genotype, respectively. Increased T-SOD activity was associated with a lower risk of DF (OR = 0.99). The rs2855262*rs10370*UF model was regarded as the optimal interaction model in generalized multifactor dimensionality reduction analyses. Our findings suggested that rs4880 and rs10370 might be useful genetic markers for DF, and there might be interactions among rs10370 in SOD2, rs2855262 in SOD3, and fluoride exposure on DF status.
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Chen T, Tao N, Yang S, Cao D, Zhao X, Wang D, Liu J. Association Between Dietary Intake of One-Carbon Metabolism-Related Nutrients and Fluorosis in Guizhou, China. Front Nutr 2021; 8:700726. [PMID: 34651006 PMCID: PMC8505735 DOI: 10.3389/fnut.2021.700726] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 08/24/2021] [Indexed: 12/01/2022] Open
Abstract
Objective: This study aimed to investigate the associations between dietary one-carbon metabolism-related nutrients (betaine, choline, methionine, folate, vitamin B6, and vitamin B12) and fluorosis among the Chinese population in an area known for coal-burning fluorosis. Methods: A cross-sectional study was conducted, with 653 fluorosis patients and 241 non-fluorosis participants. Dietary intake was acquired using a validated semi-quantitative 75-item food frequency questionnaire. The risk associations were assessed by unconditional logistical regression. Results: We observed a significant inverse association between dietary betaine, total choline, methionine, folate, vitamin B6, and choline species and fluorosis. The adjusted OR (95% CI) in the highest quartile of consumption compared with the lowest were 0.59 (0.37-0.94) (P-trend = 0.010) for betaine intake, 0.45 (0.28-0.73) (P-trend = 0.001) for total choline intake, 0.45 (0.28-0.72) (P-trend < 0.001) for methionine intake, 0.39 (0.24-0.63) (P-trend < 0.001) for folate intake, 0.38 (0.24-0.62) (P-trend < 0.001) for vitamin B6 intake, and 0.46 (0.28-0.75) (P-trend = 0.001) for total choline plus betaine intake. Dietary intakes of choline-containing compounds, phosphatidylcholine, free choline, glycerophosphocholine, and phosphocholine were also inversely associated with lower fluorosis (all P-trend < 0.05). No significant associations were observed between dietary vitamin B12 or sphingomyelin and fluorosis. Conclusion: The present study suggested that the higher dietary intakes of specific one-carbon metabolism-related nutrients, such as betaine, choline, methionine, folate, and vitamin B6, are associated with lower fluorosis prevalence.
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Affiliation(s)
- Ting Chen
- Department of Preventive Medicine, School of Public Health, Zunyi Medical University, Zunyi, China
| | - Na Tao
- Department of Pharmacy, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Sheng Yang
- Department of Surveillance in Public Health, Center for Disease Control and Prevention of Renhuai City, Renhuai, China
| | - Dafang Cao
- Department of Preventive Medicine, School of Public Health, Zunyi Medical University, Zunyi, China
| | - Xun Zhao
- Department of Chronic Diseases, Center for Diseases Control and Prevention of Zhijin County, Zhijin, China
| | - Donghong Wang
- Department of Gynaecology and Obstetrics, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Jun Liu
- Department of Preventive Medicine, School of Public Health, Zunyi Medical University, Zunyi, China
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