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Mishra A, Kumar R, Mishra SN, Vijayaraghavalu S, Shukla GC, Kumar M. Impact of smokeless tobacco on psychological and oxidative stress in unemployed indian youth. Amino Acids 2024; 56:59. [PMID: 39395920 PMCID: PMC11470867 DOI: 10.1007/s00726-024-03416-3] [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: 11/05/2023] [Accepted: 08/20/2024] [Indexed: 10/14/2024]
Abstract
In India, tobacco (nicotine) addiction among youth has increased, leading to substantial socioeconomic burdens, mortality, and morbidity. While minimal short-term nicotine consumption may have antioxidant effects, chronic exposure results in various adverse health outcomes. This study examines the impact of chronic nicotine consumption on cellular oxidative stress and psychological stress, and their correlation with Homocysteine (Hcy) levels in unemployed tobacco consumers. This case-control study included 156 healthy, educated, unemployed male volunteers aged 20-40 years, divided into nicotine-addicted (n = 80) and non-addicted (n = 76) groups. Psychological stress was assessed using perceived stress scales (PSS) and coping self-efficacy (CSE) scales. Oxidative stress markers, including Malondialdehyde (MDA), Superoxide Dismutase (SOD), and Catalase, were measured. Hcy levels were quantified using high-performance liquid chromatography (HPLC). Nicotine-addicted participants exhibited significantly higher perceived stress (p = 0.0001) and lower coping self-efficacy (p = 0.0001) compared to non-addicted individuals. MDA levels in erythrocytes were significantly increased (p = 0.0006), while SOD (p = 0.0001) and Catalase (p = 0.02) activities were significantly decreased in the addicted group. Nicotine intake influenced Hcy concentrations, with 55% of addicted individuals falling into moderate, 27.5% into intermediate, and 7.5% into severe Hcy categories. Chronic nicotine intake also reflected the hematological parameters (WBCs, RBCs, HGB, and Platelets). Chronic tobacco consumption induces oxidative stress and perceived psychological stress, leading to elevated Hcy levels in nicotine consumers. The study highlights the detrimental effects of nicotine addiction on cellular defensive mechanisms, emphasizing the need for targeted interventions to address this growing health issue among unemployed Indian youth.
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Affiliation(s)
- Anurag Mishra
- Department of Biochemistry, Faculty of Science, University of Allahabad, Prayagraj, 211002, UP, India
| | - Rishabh Kumar
- Department of Biochemistry, Faculty of Science, University of Allahabad, Prayagraj, 211002, UP, India
| | - Satya Narayan Mishra
- Maa Gayatri College of Pharmacy, Dr. A. P. J. Abdul Kalam Technical University, Prayagraj, 211008, UP, India
| | - Sivakumar Vijayaraghavalu
- Department of Life Sciences (Zoology), Manipur University (A Central University), Imphal, 795003, Manipur, India.
| | - Girish C Shukla
- Department of Biological, Geological and Environmental Sciences, 2121 Euclid Ave, Cleveland, OH, 44115, USA
- Center for Gene Regulation in Health and Disease, 2121 Euclid Ave, Cleveland, OH, 44115, USA
| | - Munish Kumar
- Department of Biochemistry, Faculty of Science, University of Allahabad, Prayagraj, 211002, UP, India.
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Zhong H, Ni X, Chen R, Hou X. Smoking contribution to the global burden of metabolic disorder: A cluster analysis. Med Clin (Barc) 2024; 163:14-20. [PMID: 38538430 DOI: 10.1016/j.medcli.2024.02.001] [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: 12/19/2023] [Revised: 02/12/2024] [Accepted: 02/12/2024] [Indexed: 07/03/2024]
Abstract
INTRODUCTION AND OBJECTIVES Smoking is associated with various health risks, including cancer, cardiovascular disease, and chronic obstructive pulmonary disease. In this retrospective cohort study, we aimed to determine whether smoking is harmful to the whole metabolic system. METHODS We collected data from 340 randomly selected participants who were divided into three groups: smokers (n=137), non-smokers (n=134), and ex-smokers (n=69). We obtained information on participants' body mass index, waist circumference, indicators of glucose metabolism, lipid metabolism, bone metabolism, and uric acid from health screen data during the past three years. A cluster analysis was used to synthesize each participant's overall metabolic characteristics. RESULTS According to the cluster analysis, the 340 participants were divided into three groups: excellent metabolizers (137, 40.3%), adverse metabolizers (32, 9.4%), and intermediate metabolizers (171, 50.3%). The Chi-squared test analysis shows that people with different smoking statuses have different metabolic patterns. Non-smokers had the highest proportion of excellent metabolizers (56%), and current smokers had the highest proportion of adverse metabolizers (15.3%). The proportion of adverse metabolizers (5.8%) in the ex-smoker group was clinically relevantly lower than that of current smokers. CONCLUSION The statistically significant differences in the distribution of smokers into different metabolic clusters indicate that smoking has adverse effects on the whole metabolic system of the human body, which further increases the existing global burden of metabolic disorders.
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Affiliation(s)
- Hua Zhong
- Department of Health Care, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xuefeng Ni
- Department of Health Care, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ruxuan Chen
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaomeng Hou
- Department of Health Care, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Schenkelaars N, van Rossem L, Willemsen SP, Faas MM, Schoenmakers S, Steegers-Theunissen RPM. The intake of ultra-processed foods and homocysteine levels in women with(out) overweight and obesity: The Rotterdam Periconceptional Cohort. Eur J Nutr 2024; 63:1257-1269. [PMID: 38383813 PMCID: PMC11139698 DOI: 10.1007/s00394-024-03334-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 01/20/2024] [Indexed: 02/23/2024]
Abstract
PURPOSE Today's diet consists of a substantial proportion of ultra-processed foods (UPF), especially in women with overweight and obesity in the reproductive period. High UPF intake results in an inadequate and unbalanced diet leading to derangements of several metabolic pathways detrimental to pregnancy and birth outcomes. Therefore, we aim to investigate whether UPF intake in the periconceptional period affects total homocysteine plasma levels (tHcy). METHODS 1532 participants were included from the prospective Rotterdam Periconceptional Cohort. UPF intake was calculated using Food Frequency Questionnaires including items classified as 4 in the Nova classification, and tHcy was measured by using liquid chromatography-tandem mass spectrometry system, with an interassay coefficient of variation of < 5.5%. Multivariable linear regression modeling was used and adjusted for covariates and significant interaction terms. RESULTS Women with overweight or obesity showed significantly higher percentage of UPF intake (respectively, 50.3 and 51.3%) and higher tHcy (respectively, 6.6 and 6.3 µmol/L, Kruskal-Wallis test; respectively, p < 0.001 and p = 0.04) compared to women with normal BMI (UPF intake: 46.8%, tHcy: 6.1 µmol/L). A 10% higher intake of UPF was associated with an increase in tHcy (adjusted: β = 1.31, 95% CI = 0.38-2.23). Analysis stratified for BMI classification showed comparable associations in normal weight participants (adjusted: β = 1.07, 95% CI = 0.06-2.07); however, no significant association in participants with overweight (adjusted: β = 0.06, 95% CI = - 0.95-1.07) and obesity (adjusted: β = 1.70, 95% CI = - 0.52-3.92) was shown. CONCLUSION This study showed that a higher intake of UPF is associated with increased tHcy. Better knowledge and awareness of the nutritional quality of the diet in the periconceptional period may contribute to 1-CM and subsequently improve pregnancy course and outcome. TRIAL REGISTRATION NUMBER AND DATE NTR4356, November 2010.
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Affiliation(s)
- Nicole Schenkelaars
- Department of Obstetrics and Gynecology, Erasmus MC, University Medical Center, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Lenie van Rossem
- Department of Obstetrics and Gynecology, Erasmus MC, University Medical Center, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Sten P Willemsen
- Department of Obstetrics and Gynecology, Erasmus MC, University Medical Center, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
- Department of Biostatistics, Erasmus MC, University Medical Center, Dr. Molewaterplein 40, 3000 CA, Rotterdam, The Netherlands
| | - Marijke M Faas
- Department of Pathology and Medical Biology, University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| | - Sam Schoenmakers
- Department of Obstetrics and Gynecology, Erasmus MC, University Medical Center, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Régine P M Steegers-Theunissen
- Department of Obstetrics and Gynecology, Erasmus MC, University Medical Center, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands.
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García-Alfaro P, Rodriguez I, Pérez-López FR. Plasma homocysteine levels and handgrip strength in postmenopausal women. Climacteric 2022; 25:504-509. [PMID: 35532029 DOI: 10.1080/13697137.2022.2068409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE This study evaluated handgrip strength (HGS), circulating homocysteine levels and related factors in postmenopausal women. METHODS This study is a sub-analysis of a prospective cohort of 303 postmenopausal women aged 62.7 ± 6.9 years who had HGS measures with a digital dynamometer as the primary outcome, and plasma homocysteine and creatinine levels and glomerular filtration rate (GFR) measures as the secondary outcomes. RESULTS The average HGS was 22.5 ± 4.0 kg, 29.4% of women had dynapenia (HGS < 20 kg), adiposity was 40.3 ± 5.4% and 9.57% of women had hyperhomocysteinemia (homocysteine >15 μmol/l). There were no differences between tertiles of homocysteine and HGS (p = 0.641). Plasma homocysteine levels were unrelated to HGS (r = -0.06) and correlated with age (r = 0.17), GFR (r = -0.28) and creatinine (r = 0.23). Hyperhomocysteinemia was not associated with HGS (odds ratio [OR] = 0.98 [95% confidence interval (CI): 0.89; 1.08]) or dynapenia (OR = 1.10 [95% CI: 0.45; 2.47]). The risk of presenting low HGS were not significantly associated with homocysteine (OR = -0.08 [95% CI: -0.21; 0.06]) and were associated with age (OR = -0.23 [95% CI: -0.29; -0.17]), adiposity (OR = -6.52 [95% CI: -9.53; -3.50]) and creatinine (OR = 6.22 [95% CI: 2.48; 9.97]). CONCLUSIONS HGS and dynapenia were unrelated to hyperhomocysteinemia. Age, GFR and creatinine were significantly associated with plasma homocysteine levels.
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Affiliation(s)
- P García-Alfaro
- Department of Obstetrics, Gynecology and Reproduction, Hospital Universitario Dexeus, Barcelona, Spain
| | - I Rodriguez
- Department of Obstetrics, Gynecology and Reproduction, Hospital Universitario Dexeus, Barcelona, Spain
| | - F R Pérez-López
- Department of Obstetrics and Gynecology, University of Zaragoza Faculty of Medicine, Zaragoza, Spain
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Mabhida SE, Muhamed B, Sharma JR, Apalata T, Nomatshila S, Mabasa L, Benjeddou M, Masilela C, Ziqubu K, Shabalala S, Johnson R. Methylenetetrahydrofolate Reductase Polymorphism (rs1801133) and the Risk of Hypertension among African Populations: A Narrative Synthesis of Literature. Genes (Basel) 2022; 13:631. [PMID: 35456437 PMCID: PMC9027465 DOI: 10.3390/genes13040631] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/25/2022] [Accepted: 03/29/2022] [Indexed: 02/07/2023] Open
Abstract
In this review, we have gathered and analyzed the available genetic evidence on the association between the methylenetetrahydrofolate reductase gene (MTHFR), rs1801133 and the risk of Hypertension (HTN) in African populations, which was further compared to the global data evidence. This review was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol and Human Genome Epidemiology Network (HuGENet) guidelines. Literature was retrieved through major search databases, including PubMed, Scopus, Web of Science, and African Journal Online. We identified 64 potential studies, of which 4 studies were from the African continent and 60 studies were reported globally. Among the studies conducted in Africa, only two (n = 2) reported a significant association between the MTHFR (rs1801133) and the risk of developing HTN. Only one (n = 1) study population was purely composed of black Africans, while others were of other ethnicities. Among studies conducted in other continents (n = 60), forty-seven (n = 47) studies reported a positive association between MTHFR (rs1801133) and the risk of developing HTN, whereas the remaining studies (n = 14) did not show a significant association. Available literature suggests an apparent association between rs1801133 and HTN in global regions; however, such information is still scarce in Africa, especially in the black African population.
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Affiliation(s)
- Sihle E. Mabhida
- Biomedical Research and Innovation Platform, South African Medical Research Council (SAMRC), Tygerberg 7505, South Africa; (S.E.M.); (J.R.S.); (L.M.); (S.S.)
- Department of Biotechnology, Faculty of Natural Science, University of the Western Cape, Private Bag X17, Bellville, Cape Town 7535, South Africa;
| | - Babu Muhamed
- Division of Infections Disease, University of Tennessee Health Sciences Center (UTHSC), Memphis, TN 38163, USA;
| | - Jyoti R. Sharma
- Biomedical Research and Innovation Platform, South African Medical Research Council (SAMRC), Tygerberg 7505, South Africa; (S.E.M.); (J.R.S.); (L.M.); (S.S.)
| | - Teke Apalata
- Division of Medical Microbiology, Department of Laboratory-Medicine and Pathology, Faculty of Health Sciences, Walter Sisulu University, Mthatha 5100, South Africa;
- National Health Laboratory Services, Mthatha 5100, South Africa
| | - Sibusiso Nomatshila
- Division of Preventive Medicine and Health Behavior, Department of Public Health, Faculty of Health Sciences, Walter Sisulu University, Mthatha 5100, South Africa;
| | - Lawrence Mabasa
- Biomedical Research and Innovation Platform, South African Medical Research Council (SAMRC), Tygerberg 7505, South Africa; (S.E.M.); (J.R.S.); (L.M.); (S.S.)
| | - Mongi Benjeddou
- Department of Biotechnology, Faculty of Natural Science, University of the Western Cape, Private Bag X17, Bellville, Cape Town 7535, South Africa;
| | - Charity Masilela
- Department of Biochemistry, North-West University, Mafikeng Campus, Mmabatho 2735, South Africa; (C.M.); (K.Z.)
| | - Khanyisani Ziqubu
- Department of Biochemistry, North-West University, Mafikeng Campus, Mmabatho 2735, South Africa; (C.M.); (K.Z.)
| | - Samukelisiwe Shabalala
- Biomedical Research and Innovation Platform, South African Medical Research Council (SAMRC), Tygerberg 7505, South Africa; (S.E.M.); (J.R.S.); (L.M.); (S.S.)
- Division of Medical Microbiology, Department of Laboratory-Medicine and Pathology, Faculty of Health Sciences, Walter Sisulu University, Mthatha 5100, South Africa;
- National Health Laboratory Services, Mthatha 5100, South Africa
| | - Rabia Johnson
- Biomedical Research and Innovation Platform, South African Medical Research Council (SAMRC), Tygerberg 7505, South Africa; (S.E.M.); (J.R.S.); (L.M.); (S.S.)
- Centre for Cardio-Metabolic Research in Africa, Division of Medical Physiology, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg 7505, South Africa
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Yang Y, Zeng Y, Yuan S, Xie M, Dong Y, Li J, He Q, Ye X, Lv Y, Hocher CF, Kraemer BK, Hong X, Hocher B. Prevalence and risk factors for hyperhomocysteinemia: a population-based cross-sectional study from Hunan, China. BMJ Open 2021; 11:e048575. [PMID: 34872994 PMCID: PMC8650492 DOI: 10.1136/bmjopen-2020-048575] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVES Hyperhomocysteinemia is an independent risk factor for cardiovascular diseases. We aimed to investigate the prevalence and risk factors for hyperhomocysteinemia, especially modifiable lifestyle factors, such as smoking behaviour and dietary factors. DESIGN Population-based cross-sectional study. SETTING Hunan Province, China PARTICIPANTS: A total of 4012 participants completed the study, between July 2013 and March 2014. The median age is 55 (interquartile range: 45-63) years, with 1644 males (41%) and 2368 females (59%). MAIN OUTCOME MEASURES Homocysteine level were measured by the microplate enzyme immunoassay method. Hyperthomocysteinemia was defined as ≥15 µmol/L. Questionnaire was used to investigate potential risk factors of hyperhomocysteinemia. Crude odd ratio (OR) or adjusted OR with 95% CI were determined by using univariable or multivariable logistic regression models. RESULTS The prevalence of hyperhomocysteinemia is 35.4% (45.4% vs 28.5% for men, women, respectively). One-year increase in age is significantly associated with 2% higher risk of hyperhomocysteinemia (OR=1.02, 95% CI: 1.01 to 1.03). One unit increase of BMI is associated with 5% higher risk of hyperhomocysteinemia (OR=1.05, 95% CI: 1.03 to 1.07). Compared with the non-smoker, smoking participants have a 24% higher risk of hyperhomocysteinemia (OR=1.24, 95% CI: 1.006 to 1.53), while the risk for those quitting smoking are not significantly different (OR=1.14, 95% CI: 0.85 to 1.54). compared with those consuming fruit and vegetable at least once every day, those consuming less than once every day had a significantly higher risk of hyperhomocysteinemia (OR=1.29, 95% CI:1.11 to 1.50). In addition, we found there were significant sex interaction with education level or alcohol drinking on the risk of hyperhomocysteinemia (pinteraction <0.05). CONCLUSIONS Higher BMI and older age are potential risk factors for hyperhomocysteinemia. Current smoking but not quitting smoking is associated with higher risk of hyperhomocysteinemia. Fruit and vegetable consumption may have protective effect against hyperhomocysteinemia. Alcohol consumption or education level might interact to influence the risk of hyperhomocysteinemia.
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Affiliation(s)
- Yide Yang
- Key Laboratory of Molecular Epidemiology of Hunan Province, School of Medicine, Hunan Normal University, Changsha, Hunan, China
| | - Yuan Zeng
- Key Laboratory of Molecular Epidemiology of Hunan Province, School of Medicine, Hunan Normal University, Changsha, Hunan, China
| | - Shuqian Yuan
- Key Laboratory of Molecular Epidemiology of Hunan Province, School of Medicine, Hunan Normal University, Changsha, Hunan, China
| | - Ming Xie
- Key Laboratory of Molecular Epidemiology of Hunan Province, School of Medicine, Hunan Normal University, Changsha, Hunan, China
| | - Yanhui Dong
- Institute of Child and Adolescent Health, School of Public Health, Peking University Health Science Center, Beijing, Beijing, China
| | - Jian Li
- Key Laboratory of Study and Discovery of Small Targeted Molecules of Hunan Province, School of Medicine, Hunan Normal University, Changsha, Hunan, China
| | - Quanyuan He
- Key Laboratory of Molecular Epidemiology of Hunan Province, School of Medicine, Hunan Normal University, Changsha, Hunan, China
| | - Xiangli Ye
- Key Laboratory of Molecular Epidemiology of Hunan Province, School of Medicine, Hunan Normal University, Changsha, Hunan, China
| | - Yuan Lv
- Key Laboratory of Molecular Epidemiology of Hunan Province, School of Medicine, Hunan Normal University, Changsha, Hunan, China
| | - Carl-Friedrich Hocher
- Fifth Department of Medicine (Nephrology/Endocrinology/Rheumatology), University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany
| | - Bernhard K Kraemer
- Fifth Department of Medicine (Nephrology/Endocrinology/Rheumatology), University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany
| | - Xiuqin Hong
- Key Laboratory of Molecular Epidemiology of Hunan Province, School of Medicine, Hunan Normal University, Changsha, Hunan, China
| | - Berthold Hocher
- Key Laboratory of Study and Discovery of Small Targeted Molecules of Hunan Province, School of Medicine, Hunan Normal University, Changsha, Hunan, China
- Fifth Department of Medicine (Nephrology/Endocrinology/Rheumatology), University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany
- Reproductive and Genetic Hospital of CITIC-Xiangya, Changsha, Hunan Province, China
- Institute of Medical Diagnostics, IMD Berlin, Berlin, Germany
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Omoike OE, Wang L, Oke AO, Johnson KR. Predicting bone turnover following tobacco exposure using bone alkaline phosphatase and N-telopeptide biomarkers and possible variability and effect modification of these markers by race/ethnicity. Biomarkers 2020; 25:410-416. [PMID: 32519586 DOI: 10.1080/1354750x.2020.1781260] [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: 02/27/2020] [Accepted: 06/03/2020] [Indexed: 10/24/2022]
Abstract
Introduction: This study investigated the systemic response of serum bone alkaline phosphatase (SBAP) and urinary N-telopeptide (UNTX) to tobacco exposure and environmental tobacco smoke (ETS) and the possible effect modification (and variability) of this response by racial/ethnic origin.Methods: Data (n = 5411) were obtained from the National Health and Nutrition Examination Survey, with data analysis done on adults aged ≥ 20 years. Outcome variables were SBAP and UNTX. Independent variable was tobacco exposure measured using serum cotinine levels and adjusted for covariates. Generalized linear models were used to explore associations.Results: A percentage increase in log transformed serum cotinine was associated with a 0.005 percentage increase in log transformed SBAP (CI: 0.002, 0.008) and 0.02 percentage increase in log transformed UNTX (CI: -0.01, 0.04) with interaction between cotinine and race/ethnicity (p = 0.01). Stratifying by race/ethnicity, tobacco exposure was associated with significant decreases in UNTX among non-Hispanic Whites - 0.008(-0.014, -0.002) and Mexican Americans -0.014 (-0.025, -0.002) only. Categories of serum cotinine were associated with a monotonic increase in SBAP (p for trend <0.001) and monotonic non-linear decrease in UNTX (p for trend > 0.05).Conclusions: Tobacco and environmental tobacco exposure are associated with SBAP and increased bone formation. The response of UNTX to these exposures is modified by race/ethnicity with non-Hispanic Whites and Mexican-Americans less sensitive to the resorptive effects of tobacco exposure on bone.
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Affiliation(s)
- Ogbebor E Omoike
- Department of Biostatistics and Epidemiology, East Tennessee State University, Johnson City, TN, USA
| | - Liang Wang
- Department of Biostatistics and Epidemiology, East Tennessee State University, Johnson City, TN, USA
| | - Adekunle O Oke
- Department of Health Services Management and Policy, East Tennessee State University, Johnson City, TN, USA
| | - Kiana R Johnson
- Department of Pediatrics, Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
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