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Virtanen N, Arffman RK, Saarela U, Pesonen E, Hurskainen E, Luiro K, Rajecki M, Savukoski SM, Kangasniemi MH, Kinnunen J, Koivunen P, Piltonen T. Serum ferritin levels in women with polycystic ovary syndrome. Fertil Steril 2025:S0015-0282(25)00028-7. [PMID: 39800132 DOI: 10.1016/j.fertnstert.2025.01.004] [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: 10/24/2024] [Revised: 12/18/2024] [Accepted: 01/03/2025] [Indexed: 01/15/2025]
Abstract
OBJECTIVE To study ferritin levels, and potential factors influencing them, in women with polycystic ovary syndrome (PCOS) and investigate potential associations between ferritin levels and other parameters in these women. DESIGN Longitudinal general population-based cohort study, including data from both questionnaires and clinical measurements. SUBJECTS The study was conducted with data from the participants of the Women's Health Study, including a total of 1,918 Finnish women aged approximately 35 years. EXPOSURE Polycystic ovary syndrome was defined according to the Rotterdam criteria by the presence of at least 2 of the following findings: oligomenorrhea/amenorrhea, hyperandrogenism (clinical or biochemical), and polycystic ovarian morphology. MAIN OUTCOME MEASURES Serum ferritin levels and other parameters were determined from the cohort data, and the associations between ferritin levels and other investigated parameters were investigated with linear regression models. RESULTS Women with PCOS had significantly higher median ferritin levels than those without PCOS (51.43 μg/L vs. 44.85 μg/L). Low ferritin levels were less common among women with PCOS who had oligomenorrhea or amenorrhea compared with those among women who did not (1.5% vs. 11.8%). The median ferritin levels were also found to be lower in hyperandrogenic women with PCOS than in those with normoandrogenemia (49.96 μg/L vs. 73.50 μg/L). Women with PCOS had higher fasting insulin levels than those without PCOS (8.85 mU/L vs. 7.60 mU/L), and a positive association between fasting insulin and ferritin levels was found in the whole population (effect size, 0.0619; 95% confidence interval, 0.005-0.119). Finally, associations between ferritin levels and history of infertility were investigated in both the total population and women with PCOS; however, no significant associations were found. CONCLUSION Our results suggest that women with PCOS have higher ferritin levels than those without PCOS and that both the decreased blood loss from irregular menstruation and increased androgen levels can influence ferritin levels in women with PCOS. A metabolic connection was also found because the serum insulin levels were associated positively with the serum ferritin levels in the total population, whereas the history of infertility did not seem to be associated with the serum ferritin levels in any of the study groups.
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Affiliation(s)
- Nikke Virtanen
- Department of Obstetrics and Gynecology, Medical Research Centre, Research Unit of Clinical Medicine, University of Oulu, Oulu University Hospital, Oulu, Finland; Research Unit of Extracellular Matrix and Hypoxia, Biocenter Oulu, Faculty of Biochemistry and Molecular Medicine, University of Oulu, Oulu, Finland
| | - Riikka K Arffman
- Department of Obstetrics and Gynecology, Medical Research Centre, Research Unit of Clinical Medicine, University of Oulu, Oulu University Hospital, Oulu, Finland
| | - Ulla Saarela
- Department of Obstetrics and Gynecology, Medical Research Centre, Research Unit of Clinical Medicine, University of Oulu, Oulu University Hospital, Oulu, Finland
| | - Emilia Pesonen
- Department of Obstetrics and Gynecology, Medical Research Centre, Research Unit of Clinical Medicine, University of Oulu, Oulu University Hospital, Oulu, Finland
| | - Elisa Hurskainen
- Department of Obstetrics and Gynecology, Medical Research Centre, Research Unit of Clinical Medicine, University of Oulu, Oulu University Hospital, Oulu, Finland
| | - Kaisu Luiro
- Department of Obstetrics and Gynecology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Maria Rajecki
- Department of Obstetrics and Gynecology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Susanna M Savukoski
- Department of Obstetrics and Gynecology, Medical Research Centre, Research Unit of Clinical Medicine, University of Oulu, Oulu University Hospital, Oulu, Finland
| | - Marika H Kangasniemi
- Department of Obstetrics and Gynecology, Medical Research Centre, Research Unit of Clinical Medicine, University of Oulu, Oulu University Hospital, Oulu, Finland
| | - Jenni Kinnunen
- Department of Obstetrics and Gynecology, Medical Research Centre, Research Unit of Clinical Medicine, University of Oulu, Oulu University Hospital, Oulu, Finland
| | - Peppi Koivunen
- Research Unit of Extracellular Matrix and Hypoxia, Biocenter Oulu, Faculty of Biochemistry and Molecular Medicine, University of Oulu, Oulu, Finland
| | - Terhi Piltonen
- Department of Obstetrics and Gynecology, Medical Research Centre, Research Unit of Clinical Medicine, University of Oulu, Oulu University Hospital, Oulu, Finland.
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Suárez-Ortegón MF, McLachlan S, Fernández-Real JM, Wilson JF, Wild SH. Both low and high body iron stores relate to metabolic syndrome in postmenopausal women: Findings from the VIKING Health Study-Shetland (VIKING I). Eur J Clin Invest 2024; 54:e14312. [PMID: 39239983 DOI: 10.1111/eci.14312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Accepted: 08/26/2024] [Indexed: 09/07/2024]
Abstract
BACKGROUND There are conflicting results among studies on the association between serum ferritin (SF) and metabolic syndrome (MetS), and by groups of sex/menopausal status. To date, there are no studies on British populations. The SF-MetS association might be U/J-shaped. We evaluated whether SF was independently associated with MetS (harmonized definition) in people from Shetland, Scotland. METHODS We analysed cross-sectional data from the Viking Health Study-Shetland (589 premenopausal women [PreMW], 625 postmenopausal women [PostW] and 832 men). Logistic regressions using two approaches, one with the lowest sex and menopausal status-specific ferritin quartile (Q) as the reference and other using the middle two quartiles combined (2-3) as the reference, were conducted to estimate the SF-MetS association. The shape of the association was verified via cubic spline analyses. The associations were adjusted for age, inflammatory and hepatic injury markers, alcohol intake, smoking and BMI. RESULTS Prevalence of MetS was 18.3%. Among PostMW both low and high SF were associated with MetS (fully adjusted odds ratios [95% confidence interval] compared to the middle two quartiles combined were: 1.99 [1.17-3.38] p =.011 for Q1 and 2.10 [1.27-3.49] p =.004 for Q4) This U-shaped pattern was confirmed in the cubic spline analysis in PostMW with a ferritin range of 15-200 ug/L. In men, a positive association between ferritin quartiles with Q1 as the reference, did not remain significant after adjustment for BMI. CONCLUSION Extreme quartiles of iron status were positively associated with MetS in PostMW, while no SF-MetS associations were found in men or PreMW. The ferritin-MetS association pattern differs between populations and U/J-shaped associations may exist.
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Affiliation(s)
| | | | - José Manuel Fernández-Real
- Department of Diabetes, Endocrinology and Nutrition, Dr. Josep Trueta University Hospital, Girona, Spain
- Nutrition, Eumetabolism and Health Group, Institut d'Investigació Biomèdica de Girona (IDIBGI-CERCA), Girona, Spain
- CIBER Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain
- Department of Medical Sciences, School of Medicine, University of Girona, Girona, Spain
| | - James F Wilson
- Centre for Global Health Research, Usher Institute, Edinburgh, UK
- Centre for Genomic Medicine, Institute of Genetics and Cancer, University of Edinburgh, Western General Hospital, Edinburgh, UK
| | - Sarah H Wild
- Usher Institute, University of Edinburgh, Edinburgh, UK
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Yu L, Que T, Zhou Y, Liu Z. Dose-response relationship of serum ferritin and dietary iron intake with metabolic syndrome and non-alcoholic fatty liver disease incidence: a systematic review and meta-analysis. Front Nutr 2024; 11:1437681. [PMID: 39410926 PMCID: PMC11476413 DOI: 10.3389/fnut.2024.1437681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Accepted: 09/09/2024] [Indexed: 10/19/2024] Open
Abstract
Aim This study aims to assess the dose-response impact of iron load on systemic and hepatic metabolic disorders including metabolic syndrome (MetS) and non-alcoholic fatty liver disease (NAFLD). Methods Serum ferritin (SF) and dietary iron intake were selected to represent the indicators of iron load in the general population. PubMed, EMBASE and Web of Science databases were searched for epidemiological studies assessing the impact of SF/dietary iron intake on MetS/NAFLD occurrence. All literature was published before September 1st, 2023 with no language restrictions. Results Fifteen and 11 papers were collected with a focus on connections between SF and MetS/NAFLD, respectively. Eight papers focusing on dietary iron and MetS were included in the following meta-analysis. For the impact of SF on MetS, the pooled odds ratio (OR) of MetS was 1.88 (95% CI: 1.58-2.24) for the highest versus lowest SF categories. In males, the OR was 1.15 (95% CI: 1.10-1.21) per incremental increase in SF of 50 μg/L, while for females, each 50 μg/L increase in SF was associated with a 1.50-fold higher risk of MetS (95% CI: 1.15-1.94). For connections between SF and NAFLD, we found higher SF levels were observed in NAFLD patients compared to the control group [standardized mean difference (SMD) 0.71; 95% CI: 0.27-1.15], NASH patients against control group (SMD1.05; 95% CI:0.44-1.66), NASH patients against the NAFLD group (SMD 0.6; 95% CI: 0.31-1.00), each 50 μg/L increase in SF was associated with a 1.08-fold higher risk of NAFLD (95% CI: 1.07-1.10). For the impact of dietary iron on MetS, Pooled OR of MetS was 1.34 (95% CI: 1.10-1.63) for the highest versus lowest dietary iron categories. Conclusion Elevated SF levels is a linear relation between the incidence of MetS/NAFLD. In addition, there is a positive association between dietary iron intake and metabolic syndrome. The association between serum ferritin and metabolic syndrome may be confounded by body mass index and C-reactive protein levels.
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Affiliation(s)
- Lu Yu
- School of Medicine, Zhejiang Chinese Medical University, Hangzhou, China
- Shulan International Medical College, Zhejiang Shuren University, Hangzhou, China
- Key Laboratory of Artificial Organs and Computational Medicine in Zhejiang Province, Shulan International Medical College, Zhejiang Shuren University, Hangzhou, China
- Shulan (Hangzhou) Hospital, Hangzhou, China
| | - Ting Que
- Birth Defects Prevention and Control Institute, Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Yifeng Zhou
- Shulan International Medical College, Zhejiang Shuren University, Hangzhou, China
| | - Zhengtao Liu
- Shulan International Medical College, Zhejiang Shuren University, Hangzhou, China
- Key Laboratory of Artificial Organs and Computational Medicine in Zhejiang Province, Shulan International Medical College, Zhejiang Shuren University, Hangzhou, China
- Shulan (Hangzhou) Hospital, Hangzhou, China
- NHC Key Laboratory of Combined Multi-organ Transplantation, Key Laboratory of the Diagnosis and Treatment of Organ Transplantation, School of Medicine, Chinese Academy of Medical Sciences, First Affiliated Hospital, Zhejiang University, Hangzhou, China
- Key Laboratory of Organ Transplantation, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Aguree S, Owora A, Hawkins M, Gletsu-Miller N. Obesity modifies the association between diabetes and iron biomarkers and red cell indices in reproductive-aged women in the United States. J Investig Med 2024; 72:425-437. [PMID: 38445643 DOI: 10.1177/10815589241240059] [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] [Indexed: 03/07/2024]
Abstract
Obesity and diabetes are associated with impaired iron metabolism. We aimed to examine the independent relationship between diabetes and iron after controlling for body weight (or obesity) in women aged 20-49 years. The National Health and Nutrition Examination Survey data from 2015 to 2018 were used in this investigation. Body composition data, HbAc1, iron biomarkers (serum ferritin (SF), soluble transferrin receptor (sTfR), and body iron index (BII)), mean corpuscular volume (MCV), mean hemoglobin concentration (MCH), red cell distribution width (RDW), and hemoglobin were used. Linear regression models were used to examine how and to what extent body mass index (BMI) modified the relationship between diabetes and iron status biomarkers. A total of 1834 women aged 20-49 were included in the analysis with a mean (SD) age of 32 .2 ± 6.1 years and BMI of 29.5 ± 6.9 kg/m2. The mean SF (p = 0.014) and BII (p < 0.001) were lower, while sTfR (p < 0.001) was higher in women with diabetes than those with no diabetes. Mean estimates for MCV and MCH were lower, while RDW (p = 0.001) was higher in diabetes patients (all p < 0.001). Women with diabetes were more likely to have iron deficiency, anemia, and iron deficiency anemia than those without diabetes (18.1% vs 8.6%, p < 0.001), (24.4% vs 8.4%, p < 0.001), and (14.8% vs 5.2%, p < 0.001), respectively. Among women with obesity, those with diabetes had lower predicted ferritin (β = -0.19, p = 0.016), BII (β = -0.99, p = 0.016), and hemoglobin (β = -0.27, p = 0.042) than those without diabetes. The study shows that diabetes is linked to lower iron stores; this is exacerbated in those with obesity.
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Affiliation(s)
- Sixtus Aguree
- Department of Applied Health Science, Indiana University School of Public Health-Bloomington, Bloomington, IN, USA
| | - Arthur Owora
- Department of Pediatrics, School of Medicine, Indiana University, Indianapolis, IN, USA
- Department of Epidemiology and Biostatistics, School of Public Health, Indiana University, Bloomington, IN, USA
| | - Misty Hawkins
- Department of Health and Wellness Design, School of Public Health, Indiana University, Bloomington, IN, USA
| | - Nana Gletsu-Miller
- Department of Applied Health Science, Indiana University School of Public Health-Bloomington, Bloomington, IN, USA
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Ahanchi NS, Fischer AS, Quezada-Pinedo HG, Khatami F, Eisenga MF, Muka T, Vidal PM. Cross-sectional and longitudinal associations of Iron biomarkers and cardiovascular risk factors in pre- and postmenopausal women: leveraging repeated measurements to address natural variability. Cardiovasc Diabetol 2024; 23:158. [PMID: 38715055 PMCID: PMC11077797 DOI: 10.1186/s12933-024-02242-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 04/21/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND The association between iron biomarkers and cardiovascular disease risk factors (CVD-RFs) remains unclear. We aimed to (1) evaluate the cross-sectional and longitudinal associations between iron biomarkers (serum ferritin, transferrin saturation (TSAT), transferrin) and CVD-RFs among women, and (2) explore if these associations were modified by menopausal status. METHOD Cross-sectional and longitudinal analyses including 2542 and 1482 women from CoLaus cohort, respectively. Multiple linear regression and multilevel mixed models were used to analyse the associations between Iron biomarkers and CVD-RFs. Variability of outcomes and iron markers between surveys was accessed using intraclass correlation (ICC). RESULTS After multivariable adjustment, elevated serum ferritin levels were associated with increased insulin and glucose levels, while higher transferrin levels were linked to elevated glucose, insulin and total cholesterol, and systolic and diastolic blood pressure (p < 0.05). No association was observed between CVD-RFs and TSAT (p > 0.05). Iron biomarkers demonstrated low reliability across reproductive stages but exhibited stronger associations in the perimenopausal group. In longitudinal analysis, we found association only for transferrin with lower glucose levels [β = - 0.59, 95% CI (- 1.10, - 0.08), p = 0.02] and lower diastolic blood pressure [β = - 7.81, 95% CI (- 15.9, - 0.56), p = 0.04]. CONCLUSION In cross-sectional analysis, transferrin was associated with several CVD-RFs, and the associations did not change according to menopausal status. Conversely, in the longitudinal analyses, changes in transferrin were associated only with lower glucose and diastolic blood pressure levels. These differences might stem from the substantial longitudinal variation of iron biomarkers, underscoring the need for multiple iron measurements in longitudinal analyses.
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Affiliation(s)
- Noushin Sadat Ahanchi
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland.
- Department of Internal Medicine, Internal Medicine, Lausanne University Hospital, Lausanne, Switzerland.
| | - Amira Salomé Fischer
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Hugo G Quezada-Pinedo
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
- The Generation R Study Group, Rotterdam, Netherlands
| | - Farnaz Khatami
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
- Community Medicine Department, Tehran University of Medical Sciences, Tehran, Iran
| | - Michele F Eisenga
- Division of Nephrology, Department of Internal Medicine, University of Groningen, Groningen, Netherlands
| | - Taulant Muka
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Epistudia, Bern, Switzerland
| | - Pedro-Marques Vidal
- Department of Internal Medicine, Internal Medicine, Lausanne University Hospital, Lausanne, Switzerland.
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Ahanchi NS, Khatami F, Llanaj E, Quezada-Pinedo HG, Dizdari H, Bano A, Glisic M, Eisenga MF, Vidal PM, Muka T. The complementary roles of iron and estrogen in menopausal differences in cardiometabolic outcomes. Clin Nutr 2024; 43:1136-1150. [PMID: 38593499 DOI: 10.1016/j.clnu.2024.03.026] [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: 08/01/2023] [Revised: 02/25/2024] [Accepted: 03/24/2024] [Indexed: 04/11/2024]
Abstract
Biological hormonal changes are frequently cited as an explanatory factor of sex and menopause differences in cardiometabolic diseases (CMD) and its associated risk factors. However, iron metabolism which varies between sexes and among women of different reproductive stages could also play a role. Recent evidence suggest that iron may contribute to CMD risk by modulating oxidative stress pathways and inflammatory responses, offering insights into the mechanistic interplay between iron and CMD development. In the current review, we provide a critical appraisal of the existing evidence on sex and menopausal differences in CMD, discuss the pitfall of current estrogen hypothesis as sole explanation, and the emerging role of iron in CMD as complementary pathway. Prior to menopause, body iron stores are lower in females as compared to males, but the increase during and after menopause, is tandem with an increased CMD risk. Importantly, basic science experiments show that an increased iron status is related to the development of type 2 diabetes (T2D), and different cardiovascular diseases (CVD). While epidemiological studies have consistently reported associations between heme iron intake and some iron biomarkers such as ferritin and transferrin saturation with the risk of T2D, the evidence regarding their connection to CVD remains controversial. We delve into the factors contributing to this inconsistency, and the limitation of relying on observational evidence, as it does not necessarily imply causation. In conclusion, we provide recommendations for future studies on evaluating the potential role of iron in elucidating the sex and menopausal differences observed in CMD.
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Affiliation(s)
- Noushin Sadat Ahanchi
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland; Graduate School for Health Sciences, University of Bern, Bern, Switzerland; Department of Internal Medicine, Internal Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Farnaz Khatami
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland; Graduate School for Health Sciences, University of Bern, Bern, Switzerland; Community Medicine Department, Tehran University of Medical Sciences, Tehran, Iran
| | - Erand Llanaj
- Department of Molecular Epidemiology, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany; German Center for Diabetes Research (DZD), München-Neuherberg, Germany
| | - Hugo G Quezada-Pinedo
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland; The Generation R Study Group, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Department of Pediatrics Erasmus MC-Sophia Children's Hospital University, Rotterdam, the Netherlands
| | - Helga Dizdari
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Arjola Bano
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland; Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marija Glisic
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland; Swiss Paraplegic Research, Nottwil, Switzerland
| | - Michele F Eisenga
- Division of Nephrology, Department of Internal Medicine, University of Groningen, Groningen, Netherlands
| | - Pedro-Marques Vidal
- Department of Internal Medicine, Internal Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Merlo F, Groothof D, Khatami F, Ahanchi NS, Wehrli F, Bakker SJL, Eisenga MF, Muka T. Changes in Iron Status Biomarkers with Advancing Age According to Sex and Menopause: A Population-Based Study. J Clin Med 2023; 12:5338. [PMID: 37629382 PMCID: PMC10455248 DOI: 10.3390/jcm12165338] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 08/07/2023] [Accepted: 08/10/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND The risk of chronic diseases increases markedly with age and after menopause. An increase in bodily iron following menopause could contribute to this phenomenon of increased risk of chronic diseases. We aimed to investigate how various iron biomarkers change with advancing age, according to sex and menopausal status. METHODS We enrolled community-dwelling individuals with available information on ferritin, transferrin, iron, hepcidin, and soluble transferrin receptor levels from the Prevention of Renal and Vascular Endstage Disease study. The association of the iron biomarkers with age, sex, and menopausal status was investigated with linear regression models. RESULTS Mean (SD) age of the 5222 individuals (2680 women [51.3%], among whom 907 [33.8%] were premenopausal, 529 [19.7%] perimenopausal, and 785 [29.3%] postmenopausal), was 53.4 (12.0) years. Iron biomarkers showed a constant increase in women throughout their life course, in some cases at older ages surpassing values in men who, in turn, showed consistently higher levels of iron status compared to women in most age categories. Ferritin, hepcidin, and transferrin saturation levels were 3.03, 2.92, and 1.08-fold (all p < 0.001) higher in postmenopausal women compared to premenopausal. CONCLUSIONS We found that iron accumulates differently depending on sex, age, and menopausal status. An increased iron status was identified in women, especially during and after menopause.
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Affiliation(s)
- Francesco Merlo
- Institute of Social and Preventive Medicine, University of Bern, 3012 Bern, Switzerland; (F.M.); (F.K.); (N.S.A.)
| | - Dion Groothof
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands; (D.G.); (S.J.L.B.); (M.F.E.)
| | - Farnaz Khatami
- Institute of Social and Preventive Medicine, University of Bern, 3012 Bern, Switzerland; (F.M.); (F.K.); (N.S.A.)
- Graduate School for Health Sciences, University of Bern, 3012 Bern, Switzerland
- Community Medicine Department, Tehran University of Medical Sciences, Tehran 1417613151, Iran
| | - Noushin Sadat Ahanchi
- Institute of Social and Preventive Medicine, University of Bern, 3012 Bern, Switzerland; (F.M.); (F.K.); (N.S.A.)
- Graduate School for Health Sciences, University of Bern, 3012 Bern, Switzerland
- Department of Internal Medicine, Internal Medicine, Lausanne University Hospital, Rue de Bugnon 21, 1005 Lausanne, Switzerland
| | - Faina Wehrli
- Dr. Risch, Lagerstrasse 30, 9470 Buchs, Switzerland;
| | - Stephan J. L. Bakker
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands; (D.G.); (S.J.L.B.); (M.F.E.)
| | - Michele F. Eisenga
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands; (D.G.); (S.J.L.B.); (M.F.E.)
| | - Taulant Muka
- Epistudia, Schanzenstrasse 4a, 3008 Bern, Switzerland
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Zhu Z, Wang Z, Zang J, Lu Y, Xiao Z, Zheng G, Wu F. The SNP rs516946 Interacted in the Association of MetS with Dietary Iron among Chinese Males but Not Females. Nutrients 2022; 14:nu14102024. [PMID: 35631165 PMCID: PMC9147551 DOI: 10.3390/nu14102024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 05/04/2022] [Accepted: 05/09/2022] [Indexed: 02/04/2023] Open
Abstract
This study aimed to explore the role of the single nucleotide polymorphism (SNP) rs516946 of the Ankyrin 1 (ANK1) gene in the relationship between dietary iron and metabolic syndrome (MetS) in the Chinese population. A total of 2766 Chinese adults (1284 males and 1482 females) were recruited. A 3-day 24-h dietary recall and weighing of household condiments were used to assess dietary intake. Anthropometric and laboratory measurements were obtained. After adjusting for age, region, years of education, intentional physical exercise, physical activity level, smoking, alcohol use and energy intake, dietary iron and the SNP rs516946 were both correlated with MetS risk and interacted among the male participants. The trend between dietary iron and MetS risk remained among T allele non-carriers of males but not among T allele carriers of males. Both the SNP rs516946 and the ferritin level correlated positively with the aspartate aminotransferase (AST) level. ANK1 SNP rs516946 interacted in the association of MetS with dietary iron among Chinese males while no association was found among females. Periodic blood loss might prevent females from these associations. The SNP rs516946 might correlate with liver function.
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Affiliation(s)
- Zhenni Zhu
- Division of Health Risk Factors Monitoring and Control, Shanghai Municipal Center for Disease Control and Prevention, 1380 West Zhongshan Road, Shanghai 200336, China; (Z.Z.); (Z.W.); (J.Z.); (Y.L.)
| | - Zhengyuan Wang
- Division of Health Risk Factors Monitoring and Control, Shanghai Municipal Center for Disease Control and Prevention, 1380 West Zhongshan Road, Shanghai 200336, China; (Z.Z.); (Z.W.); (J.Z.); (Y.L.)
| | - Jiajie Zang
- Division of Health Risk Factors Monitoring and Control, Shanghai Municipal Center for Disease Control and Prevention, 1380 West Zhongshan Road, Shanghai 200336, China; (Z.Z.); (Z.W.); (J.Z.); (Y.L.)
| | - Ye Lu
- Division of Health Risk Factors Monitoring and Control, Shanghai Municipal Center for Disease Control and Prevention, 1380 West Zhongshan Road, Shanghai 200336, China; (Z.Z.); (Z.W.); (J.Z.); (Y.L.)
| | - Ziyi Xiao
- Department of Social Science, New York University Shanghai, Shanghai 200122, China;
| | - Guangyong Zheng
- Bio-Med Big Data Center, Shanghai Institute of Nutrition and Health, Chinese Academy of Sciences, Shanghai 200031, China
- Correspondence: (G.Z.); (F.W.)
| | - Fan Wu
- Shanghai Medical College, Fudan University, 130 Dongan Road, Shanghai 200032, China
- Correspondence: (G.Z.); (F.W.)
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Zhang Y, Ke Y, Huang L, Shen X, Yan S, Zhao F, Li Y, Lin Y. Association of decreased muscle mass with reduced bone mineral density in patients with Graves' disease. Endocrine 2022; 75:916-926. [PMID: 35064543 DOI: 10.1007/s12020-021-02960-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 12/04/2021] [Indexed: 11/03/2022]
Abstract
AIM This study aimed to determine the association of decreased muscle mass with reduced bone mineral density in patients with Graves' disease. METHODS A total of 758 patients with Graves' disease at diagnosis (mean age 41.2 years) were enrolled for a cross-sectional study; of these, 287 were enrolled for a cohort study with a median follow-up of 24 months. Meanwhile, 1164 age- and sex-matched healthy controls were recruited. All participants underwent dual-energy x-ray absorptiometry and muscle mass index (ASMI) measurements. The changes in ASMI and bone mineral density (BMD) were calculated from the measurements made at a gap of 2 years. RESULTS The BMD of patients with Graves' disease was still significantly lower after normalizing serum thyroid hormone levels compared with that of healthy controls. ASMI positively correlated with BMD in patients with Graves' disease (lumbar BMD, r = 0.210; femoral neck BMD, r = 0.259; hip BMD, r = 0.235; P < 0.001), and this relationship persisted after successful anti-thyroid therapy (lumbar BMD, r = 0.169; femoral neck BMD, r = 0.281; hip BMD, r = 0.394; P < 0.001). Low muscle mass was associated with low BMD (OR, 1.436; 95% CI, 1.026-2.010). Improving the muscle mass led to changes in the bone mass of the femoral neck (OR, 0.420; 95% CI, 0.194-0.911) and hip (OR, 0.217; 95% CI, 0.092-0.511) during the follow-up. However, this phenomenon was not observed in lumbar and bone turnover markers. CONCLUSIONS The recovery of bone mass might be related to the recovery of the muscle mass. Patients with Graves' disease should be helped to regain their muscle mass and thus accelerate the recovery of bone mass while administering anti-thyroid therapy.
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Affiliation(s)
- Yongze Zhang
- Department of Endocrinology, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong Road, Fuzhou, 350005, Fujian, China
- Clinical Research Center for Metabolic Diseases of Fujian Province, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong Road, Fuzhou, 350005, Fujian, China
- Diabetes Research Institute of Fujian Province, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong Road, Fuzhou, 350005, Fujian, China
- Metabolic Diseases Research Institute, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong Road, Fuzhou, 350005, Fujian, China
| | - Yuzhen Ke
- Department of Endocrinology, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong Road, Fuzhou, 350005, Fujian, China
- Clinical Research Center for Metabolic Diseases of Fujian Province, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong Road, Fuzhou, 350005, Fujian, China
- Diabetes Research Institute of Fujian Province, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong Road, Fuzhou, 350005, Fujian, China
- Metabolic Diseases Research Institute, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong Road, Fuzhou, 350005, Fujian, China
| | - Lingning Huang
- Department of Endocrinology, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong Road, Fuzhou, 350005, Fujian, China
- Clinical Research Center for Metabolic Diseases of Fujian Province, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong Road, Fuzhou, 350005, Fujian, China
- Diabetes Research Institute of Fujian Province, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong Road, Fuzhou, 350005, Fujian, China
- Metabolic Diseases Research Institute, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong Road, Fuzhou, 350005, Fujian, China
| | - Ximei Shen
- Department of Endocrinology, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong Road, Fuzhou, 350005, Fujian, China
- Clinical Research Center for Metabolic Diseases of Fujian Province, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong Road, Fuzhou, 350005, Fujian, China
- Diabetes Research Institute of Fujian Province, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong Road, Fuzhou, 350005, Fujian, China
- Metabolic Diseases Research Institute, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong Road, Fuzhou, 350005, Fujian, China
| | - Sunjie Yan
- Department of Endocrinology, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong Road, Fuzhou, 350005, Fujian, China.
- Clinical Research Center for Metabolic Diseases of Fujian Province, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong Road, Fuzhou, 350005, Fujian, China.
- Diabetes Research Institute of Fujian Province, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong Road, Fuzhou, 350005, Fujian, China.
- Metabolic Diseases Research Institute, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong Road, Fuzhou, 350005, Fujian, China.
| | - Fengying Zhao
- Department of Endocrinology, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong Road, Fuzhou, 350005, Fujian, China
- Clinical Research Center for Metabolic Diseases of Fujian Province, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong Road, Fuzhou, 350005, Fujian, China
- Diabetes Research Institute of Fujian Province, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong Road, Fuzhou, 350005, Fujian, China
- Metabolic Diseases Research Institute, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong Road, Fuzhou, 350005, Fujian, China
| | - Yimei Li
- Department of Endocrinology, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong Road, Fuzhou, 350005, Fujian, China
- Clinical Research Center for Metabolic Diseases of Fujian Province, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong Road, Fuzhou, 350005, Fujian, China
- Diabetes Research Institute of Fujian Province, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong Road, Fuzhou, 350005, Fujian, China
- Metabolic Diseases Research Institute, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong Road, Fuzhou, 350005, Fujian, China
| | - Yuxi Lin
- Department of Endocrinology, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong Road, Fuzhou, 350005, Fujian, China
- Clinical Research Center for Metabolic Diseases of Fujian Province, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong Road, Fuzhou, 350005, Fujian, China
- Diabetes Research Institute of Fujian Province, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong Road, Fuzhou, 350005, Fujian, China
- Metabolic Diseases Research Institute, the First Affiliated Hospital of Fujian Medical University, 20 Cha Zhong Road, Fuzhou, 350005, Fujian, China
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10
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The association between the metabolic syndrome and iron status in pre- and postmenopausal women: Korean National Health and Nutrition Examination Survey (KNHANES) in 2012. Br J Nutr 2021; 127:630-640. [PMID: 33899716 DOI: 10.1017/s0007114521001331] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
We aim to determine the association between Fe status and the metabolic syndrome (MetS) during menopause. Records of 1069 premenopausal and 703 postmenopausal Korean women were retrieved from the database of the fifth Korean National Health and Nutrition Examination Survey (KNHANES V 2012) and analysed. The association between the MetS and Fe status was performed using multivariable-adjusted analyses, subsequently develop a prediction model for the MetS by margin effects. We found that the risk of Fe depletion among postmenopausal women was lower than premenopausal women (PR = 0·813, 95 % CI 0·668, 0·998, P = 0·038). The risk of the MetS was 2·562-fold lower among premenopausal women with than without Fe depletion (PR = 0·390, 95 % CI 0·266, 0·571, P < 0·001). In contrast, the risk of the MetS tended to be higher among postmenopausal women with than without Fe depletion (PR = 1·849, 95 % CI 1·406, 2·432, P < 0·001). When the serum ferritin levels increased, the risk of the MetS increased in both premenopausal women and postmenopausal women. The margin effects showed that an increase in serum Hb and ferritin was associated with an increase in the risk of the MetS according to menopausal status and age group. Therefore, ferritin is the most validated and widely used Fe marker, could be a potential clinical value in predicting and monitoring the MetS during menopause. Further prospective or longitudinal studies, especially, clinically related studies on menopause and Fe status, are needed to clarify the causality between serum ferritin levels and the MetS that could offer novel treatments for the MetS.
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11
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Association of Iron Storage Markers with Metabolic Syndrome and Its Components in Chinese Rural 6-12 Years Old Children: The 2010-2012 China National Nutrition and Health Survey. Nutrients 2020; 12:nu12051486. [PMID: 32443740 PMCID: PMC7284848 DOI: 10.3390/nu12051486] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 04/30/2020] [Accepted: 05/18/2020] [Indexed: 12/28/2022] Open
Abstract
Background: Elevated ferritin, which is often used to represent iron storage, is known to increase the risk of metabolic syndrome (MetS) or its components, but its increase is affected by many factors. Therefore, it is necessary to analyze the relationship between other indicators of iron storage, and MetS and its components in order to fully understand the role of iron in the occurrence and development of these diseases. Although there are many studies to analyze the relationship involved in adults and adolescents, in children there is limited research. In this study, we aim to estimate the association of whole blood iron, ferritin, and total body iron with metabolic syndrome, and especially its components in Chinese rural children aged 6–12 years old. Method: A total of 1333 children aged 6–12 years old were enrolled from the 2010–2012 China National Nutrition and Health Survey in this study. Markers of iron storage (whole blood iron, ferritin, and total body iron (TBI)) and MetS component parameters (waist, blood pressure, high-density lipoprotein cholesterol (HDL-C), triglyceride (TG), and fast glycose) were collected. A multivariate logistic regression analysis was performed to confirm the independent relationship between iron storage markers, and the incident of metabolic syndrome and its components. Results: After adjusting for age, gender, C-reactive protein (CRP), and body mass index (BMI), a negative association was found between whole blood iron, ferritin, and TBI and incidence of reduced HDL-C (odds ratio (OR) = 0.63, 0.49, and 0.57, respectively). The highest tertile of whole blood iron increased the risk of the incidence of hyperglycemia (OR = 1.74), while TBI decreased the risk by 61%. No significant association was found between ferritin tertiles and the incidence of hyperglycemia. Conclusion: An iron storage level within the normal range in children is associated with a risk of MetS components, especially in hyperglycemia and reduced HDL-C. The relationship between the three iron indexes and metabolic syndrome and its components is not completely consistent, which suggests that the underlying mechanism is complex and needs to be further explored.
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12
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Serum ferritin levels are associated with insulin resistance in Chinese men and post-menopausal women: the Shanghai Changfeng study. Br J Nutr 2018; 120:863-871. [PMID: 30189905 DOI: 10.1017/s0007114518002167] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Associations between ferritin and insulin sensitivity have been described in recent studies. The possible association showed conflicting results by sex and menopausal status. We aimed to investigate the cross-sectional association of ferritin levels with insulin resistance and β-cell function. A total of 2518 participants (1033 men, 235 pre-menopausal women and 1250 post-menopausal women) were enrolled from the Changfeng Study. A standard interview was conducted, as well as anthropometric measurements and laboratory analyses, for each participant. The serum ferritin level was measured using electrochemiluminescence immunoassay. Insulin resistance and β-cell function indices were derived from a homeostasis model assessment. The results showed that the serum ferritin levels were 250·4 (sd 165·2), 94·6 (sd 82·0) and 179·8 (sd 126·6) ng/ml in the men, pre-menopausal and post-menopausal women, respectively. In fully adjusted models (adjusting for age, current smoking, BMI, waist:hip ratio, systolic blood pressure, diastolic blood pressure, TAG, HDL-cholesterol, LDL-cholesterol, log urine albumin:creatinine ratio, leucocytes, alanine aminotransferase, aspartate aminotransferase and γ-glutamyl transpeptidase), serum ferritin concentrations are significantly associated with insulin resistance in men and post-menopausal females, and the null association was observed in pre-menopausal females. Interestingly, an increased β-cell function associated with higher ferritin was observed in post-menopausal participants, but not in male participants. In conclusion, these results suggested that elevated serum ferritin levels were associated with surrogate measures of insulin resistance among the middle-aged and elderly male and post-menopausal women, but not in pre-menopausal women.
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Suárez-Ortegón MF, Ensaldo-Carrasco E, Shi T, McLachlan S, Fernández-Real JM, Wild SH. Ferritin, metabolic syndrome and its components: A systematic review and meta-analysis. Atherosclerosis 2018; 275:97-106. [PMID: 29886355 DOI: 10.1016/j.atherosclerosis.2018.05.043] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 05/03/2018] [Accepted: 05/22/2018] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND AIMS Mechanisms for the association between iron stores and risk factors for diabetes and cardiovascular disease, such as metabolic syndrome (MetS) and its components, are still not clear. We evaluated the associations between ferritin levels, MetS and its individual components, and potential role of confounding, in a meta-analysis. METHODS We searched articles in MEDLINE and EMBASE until February 14th, 2018. There were two approaches: meta-analysis of 1) cross-sectional and longitudinal studies and 2) only cross-sectional studies. Meta-regressions were conducted to identify sources of heterogeneity in the associations of ferritin with MetS and its individual components. RESULTS Information from 26 studies (5 prospective) was systematically reviewed and 21 studies were meta-analysed. The pooled OR for MetS by increased ferritin was 1.78 (95%CI: 1.60-1.97) in the meta-analysis 1, and 1.70 (95%CI: 1.49-1.95) in the meta-analysis 2. The pooled association was weaker in studies adjusted for hepatic injury markers (meta-regression coefficient (95% CI): -0.34 (-0.60,-0.09) p = 0.008) and body mass index (BMI) (meta-regression coefficient (95% CI): -0.27 (-0.53,-0.01) p = 0.039). Among MetS components, the pooled association with increased ferritin was strongest with high triglycerides [OR (95%CI): 1.96 (1.65-2.32)] and high glucose levels [OR 95%CI: 1.60 (1.40-1.82)]. Higher cut-off points used to define high ferritin concentrations were more strongly associated with high triglycerides [meta-regression coefficient (95% CI): 0.22 (0.03, 0.041), p = 0.023]. CONCLUSIONS High triglycerides and glucose are the components more strongly associated with ferritin. Hepatic injury and BMI appear to influence the ferritin-MetS association, and a threshold effect of high ferritin concentration on the ferritin-high triglycerides association was observed.
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Affiliation(s)
- Milton Fabian Suárez-Ortegón
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, Scotland, United Kingdom; Nutrition Group, Universidad del Valle, Cali, Colombia.
| | - Eduardo Ensaldo-Carrasco
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Ting Shi
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Stela McLachlan
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - José Manuel Fernández-Real
- Department of Diabetes, Endocrinology and Nutrition, Institut d'Investigació Biomèdica de Girona, CIBEROBN (CB06/03/010) and Instituto de Salud Carlos III (ISCIII), Girona, Spain.
| | - Sarah H Wild
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, Scotland, United Kingdom
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14
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Chen Z, Zhu B, Ou C, Li Y. Serum ferritin and primary lung cancer. Oncotarget 2017; 8:92643-92651. [PMID: 29190945 PMCID: PMC5696211 DOI: 10.18632/oncotarget.21518] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 09/04/2017] [Indexed: 01/10/2023] Open
Abstract
Existing research yields conflicting results regarding the relation between iron deficiency and high serum ferritin (SF) levels in primary lung cancer patients. We investigated the concentrations of SF, hemoglobin (Hb) and transferrin (TRF) in 569 male primary lung cancer patients and 252 female primary lung cancer patients. We grouped the subjects according to gender, smoking status, menopausal status, pathological type, stage, and TNM stage. The levels of SF and TRF were correlated with T stage in male patients (p<0.01). The levels of SF and TRF were correlated with menopausal status in female patients (p<0.01). Hb was correlated with smoking status, pathological type, stage, and TNM stages in male patients(p<0.01), but in female patients, Hb was not correlated with these grouping factors(p>0.05). The levels of SF may be regulated by different mechanisms and may be of different physiological significance in different populations.
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Affiliation(s)
- Zhongqing Chen
- Department of Clinical Laboratory, Guangxi Medical University Affiliated Tumor Hospital, Nanning 530021, Guangxi Province, P.R. China
| | - Bo Zhu
- Department of Clinical Laboratory, Guangxi Medical University Affiliated Tumor Hospital, Nanning 530021, Guangxi Province, P.R. China
| | - Chao Ou
- Experimental Research Department, Guangxi Medical University Affiliated Tumor Hospital, Nanning 530021, Guangxi Province, P.R. China
| | - Yuxuan Li
- Department of Hepatobiliary Surgery, Guangxi Medical University Affiliated Tumor Hospital, Nanning 530021, Guangxi Province, P.R. China
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15
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Kim MK, Chon SJ, Noe EB, Roh YH, Yun BH, Cho S, Choi YS, Lee BS, Seo SK. Associations of dietary calcium intake with metabolic syndrome and bone mineral density among the Korean population: KNHANES 2008-2011. Osteoporos Int 2017; 28:299-308. [PMID: 27503170 DOI: 10.1007/s00198-016-3717-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 07/20/2016] [Indexed: 10/21/2022]
Abstract
UNLABELLED Excessive amount of calcium intake increased risk for metabolic syndrome in men. However, modest amount decreased the risk of metabolic syndrome and osteoporosis in postmenopausal women. Modest amount of calcium also increased bone mineral density (BMD) in both men and postmenopausal women. INTRODUCTION The present study aimed to evaluate the associations of dietary calcium intake with metabolic syndrome and bone mineral density (BMD) in Korean men and women, especially postmenopausal women. METHODS The study was performed using data from the Korean National Health and Nutrition Examination Survey (2008-2011) and included 14,705 participants (5953 men, 4258 premenopausal women, and 4494 postmenopausal women). Clinical and other objective characteristics, presence of metabolic syndrome, and the BMD of the femur neck and lumbar spine were evaluated according to dietary calcium intake. RESULTS There was a higher tendency for metabolic syndrome in men with a dietary calcium intake of >1200 mg/day than with ≤400 mg of calcium intake; >400 and ≤800 mg of calcium intake was helpful for postmenopausal women to decrease risk for metabolic syndrome. Overall, the group with calcium intake >400 and ≤800 mg daily had significantly increased BMD in both femoral neck and lumbar spine from both men and postmenopausal women. From both femoral neck and lumbar spine, the prevalence of osteoporosis in postmenopausal women significantly decreased in the group whose calcium intake was >400 and ≤800 mg daily. CONCLUSION Excessive dietary calcium may increase the prevalence of metabolic syndrome in men. For postmenopausal women, calcium intake does not increase the risk of metabolic syndrome, but modest amount decreases the risk. It may increase the BMD in men and postmenopausal women, and also reduce the prevalence of both osteoporosis and metabolic syndrome in postmenopausal women.
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Affiliation(s)
- M K Kim
- Department of Obstetrics and Gynecology, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
- Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - S J Chon
- Department of Obstetrics and Gynecology, Gil Hospital, Gachon University College of Medicine, Incheon, Republic of Korea
| | - E B Noe
- Seoul Rachel Fertility Center, Seoul, Republic of Korea
| | - Y H Roh
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - B H Yun
- Department of Obstetrics and Gynecology, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
- Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - S Cho
- Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Republic of Korea
- Department of Obstetrics and Gynecology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Y S Choi
- Department of Obstetrics and Gynecology, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
- Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - B S Lee
- Department of Obstetrics and Gynecology, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
- Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - S K Seo
- Department of Obstetrics and Gynecology, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
- Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Soluble transferrin receptor levels are positively associated with insulin resistance but not with the metabolic syndrome or its individual components. Br J Nutr 2016; 116:1165-1174. [PMID: 27605239 DOI: 10.1017/s0007114516002968] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The metabolic syndrome (MetS) is known to be associated with elevated serum ferritin levels. The possible association with other Fe markers has been less well studied. We aimed to investigate the cross-sectional association of soluble transferrin receptor (sTfR) and ferritin levels with the MetS components, insulin resistance and glycosylated Hb (HbA1C). The sample consisted of 725 adults, aged 19-93 years (284 men, 151 premenopausal and 290 postmenopausal women), from the Croatian island of Vis. Serum sTfR and ferritin levels were measured by immunoturbidimetry and electrochemiluminescence assays, respectively. The MetS was defined using modified international consensus criteria. Logistic and linear regression analyses were conducted to investigate the associations adjusting for age, fibrinogen, smoking status, alcohol consumption and BMI. Prevalence of the MetS was 48·7 %. Standardised values of ferritin were positively associated with all of the MetS components (except high blood pressure and waist circumference) in men (P0·05). sTfR levels could be spuriously elevated in subjects with insulin resistance and without association with the MetS or its components. We conclude that different markers of Fe metabolism are not consistently associated with cardiometabolic risk.
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Ju SY, Ha AW. Dietary factors associated with high serum ferritin levels in postmenopausal women with the Fifth Korea National Health and Nutrition Examination Survey (KNHANES V), 2010-2012. Nutr Res Pract 2015; 10:81-8. [PMID: 26865920 PMCID: PMC4742315 DOI: 10.4162/nrp.2016.10.1.81] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 11/05/2015] [Accepted: 11/09/2015] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND/OBJECTIVES Serum ferritin levels are significantly increased after menopause and greatly affect women's health. The aim of this study was to investigate the dietary and non-dietary factors associated with high ferritin levels in postmenopausal women. SUBJECTS/METHODS Among adult women in 2010-2012, qualified postmenopausal women (n = 3880) were separated into quartiles of serum ferritin. The variable differences among the quartiles of ferritin were determined using either procsurvey chi-square test (χ2-test) among categorical variables, or GLM (Generalized Linear Model) among continuous variables. The odds ratio for high ferritin in relation to dietary factors was also determined using procsurvery logistic analysis. RESULTS Age, obesity, drinking habit, and blood glucose levels were found to be significant indicators of high serum ferritin level after adjusting for all confounding factors. Among the food groups, grain, milk, vegetable, and seaweed intakes were significantly associated with high ferritin levels, but after adjusting for all confounding factors, only grains and vegetables remained significant factors. Among the nutrient groups, calcium, vitamin A, and vitamin C intake were significant factors, but after adjustment, none of the nutrient groups analyzed were associated with a high risk of ferritin. CONCLUSION Age, obesity, drinking habit, and glucose levels, as well as inadequate intakes of grains and vegetables, were found to be significantly associated with high serum ferritin levels in postmenopausal Korean women.
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Affiliation(s)
- Se Young Ju
- Department of Food Science and Nutrition, Natural Nutraceuticals Industrization Research Center, DanKook University, 152 Jukjeon-Ro, Suji-Gu, Yongin-Si, Gyeonggi 16890, Korea
| | - Ae Wha Ha
- Department of Food Science and Nutrition, Natural Nutraceuticals Industrization Research Center, DanKook University, 152 Jukjeon-Ro, Suji-Gu, Yongin-Si, Gyeonggi 16890, Korea
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18
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Kilani N, Vollenweider P, Waeber G, Marques-Vidal P. Iron metabolism and incidence of metabolic syndrome. Nutr Metab Cardiovasc Dis 2015; 25:1025-1032. [PMID: 26315622 DOI: 10.1016/j.numecd.2015.07.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 07/10/2015] [Accepted: 07/13/2015] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND AIMS Whether iron metabolism affects metabolic syndrome (METS) is debated. We assessed the association between several markers of iron metabolism and incidence of METS. METHODS AND RESULTS Data from 3271 participants (1870 women, 51.3 ± 10.4 years), free of METS at baseline and followed for 5.5 years. The association of serum iron, ferritin and transferrin with incident METS was assessed separately by gender. Incidence of METS was 22.6% in men and 16.5% in women (p < 0.001). After multivariate adjustment, a positive association was found between transferrin and incident METS in men: odds ratio (OR) and 95% confidence interval for the fourth relative to the first quartile 1.55 (1.04-2.31), p for trend = 0.03, while no association was found for iron OR = 0.81 (0.53-1.24), p for trend = 0.33 and ferritin OR = 1.30 (0.88-1.92), p for trend = 0.018. In women, a negative association was found between iron and incident METS: OR for the fourth relative to the first quartile 0.51 (0.33-0.80), p for trend<0.03; the association between transferrin and incident METS was borderline significant: OR = 1.45 (0.97-2.17), p for trend = 0.07 and no association was found for ferritin: OR = 1.11 (0.76-1.63), p for trend = 0.58. CONCLUSION Transferrin, not ferritin, is independently associated with an increased risk of incident METS; the protective effect of iron in women should be further explored.
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Affiliation(s)
- N Kilani
- Department of Internal Medicine, Internal Medicine, Lausanne University Hospital, Lausanne, Switzerland.
| | - P Vollenweider
- Department of Internal Medicine, Internal Medicine, Lausanne University Hospital, Lausanne, Switzerland.
| | - G Waeber
- Department of Internal Medicine, Internal Medicine, Lausanne University Hospital, Lausanne, Switzerland.
| | - P Marques-Vidal
- Department of Internal Medicine, Internal Medicine, Lausanne University Hospital, Lausanne, Switzerland.
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Stefanska A, Bergmann K, Sypniewska G. Metabolic Syndrome and Menopause: Pathophysiology, Clinical and Diagnostic Significance. Adv Clin Chem 2015; 72:1-75. [PMID: 26471080 DOI: 10.1016/bs.acc.2015.07.001] [Citation(s) in RCA: 163] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Menopause is a risk factor for cardiometabolic diseases, including metabolic syndrome (MetS), type 2 diabetes, and cardiovascular diseases. MetS is a constellation of interdependent factors such as insulin resistance, abdominal obesity, dyslipidemia, and hypertension. The prevalence of MetS in postmenopause is due to loss of the protective role of estrogens and increased circulating androgens resulting in changes to body fat distribution and development of abdominal obesity. Excessive visceral adipose tissue plays an important role due to synthesis and secretion of bioactive substances such as adipocytokines, proinflammatory cytokines, reactive oxygen species, prothrombotic, and vasoconstrictor factors. MetS may also impact risk assessment of breast cancer, osteoporosis and chronic kidney disease, and quality of life during the menopausal transition. Increased MetS has stimulated the exploration of new laboratory tests for early detection and therapies.
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Affiliation(s)
- Anna Stefanska
- Department of Laboratory Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland.
| | - Katarzyna Bergmann
- Department of Laboratory Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Grazyna Sypniewska
- Department of Laboratory Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
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Yegin ZA, İyidir ÖT, Demirtaş C, Suyanı E, Yetkin İ, Paşaoğlu H, İlhan Ç, Sucak GT. The interplay among iron metabolism, endothelium and inflammatory cascade in dysmetabolic disorders. J Endocrinol Invest 2015; 38:333-8. [PMID: 25245337 DOI: 10.1007/s40618-014-0174-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 09/08/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE Metabolic syndrome (MetS) is considered as a proinflammatory and prothrombotic state with atherogenic risk factors including dyslipidemia, obesity and glucose intolerance. Oxidative stress is a unifying basis of several disorders including diabetes mellitus (DM) and MetS. We therefore designed this cross-sectional study to investigate the potential interaction among iron metabolism, inflammation and endothelial plexus in MetS and DM patients. METHODS A total of 62 patients [median age 54 (23-76) years; male/female 16/46] and 18 healthy controls [median age 38 (30-64) years; male/female 6/12] were included in the study. Patient population was classified as MetS (n = 30) and DM (n = 32). RESULTS Leukocyte count (p = 0.002) and osteopontin (OPN) levels (p = 0.008) were significantly higher, while C-reactive protein (CRP) (p = 0.056) and IL-6 (p = 0.059) represented a relative increase in the patient group. Leptin, endothelin 1 (ET1), hepcidin, nitric oxide synthase (NOS), erythrocyte sedimentation rate (ESR), iron, transferrin saturation (TS) and ferritin levels were not significantly different between the patient and control groups. Endothelin 1 was found to be higher in the DM group compared to MetS group (p = 0.15, p = 0.049). Leukocyte count, leptin, hepcidin, OPN, NOS, IL-6, ESR, CRP, iron, TS and ferritin levels were not different between DM and MetS groups. A positive correlation was demonstrated between leptin and OPN (p = 0.001, r = 0.360), ferritin and hepcidin (p < 0.01, r = 0.633), IL-6 and CRP (p = 0.023, r = 0.319), leptin and NOS (p = 0.005, r = 0.309) and OPN and NOS (p < 0.001, r = 0.803). There was a negative correlation between hepcidin and NOS (p = 0.009, r = -0.289). When the study cohort was divided into two particular groups based on median ferritin and hepcidin levels, hepcidin (p = 0.002), ALT (p = 0.001) and LDL (p = 0.049) levels were higher in the high-ferritin group. Nitric oxide synthase levels (p = 0.033) were lower, whereas ferritin levels (p = 0.004) were higher in the high-hepcidin group. CONCLUSION Mechanisms involved in the vicious circle of MetS including inflammation, endothelial vasculature and iron metabolism remain to be elucidated. The role of iron metabolism in this complex interaction should be confirmed with further studies.
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Affiliation(s)
- Z A Yegin
- Department of Hematology, Gazi University Faculty of Medicine, Beşevler, Ankara, Turkey.
| | - Ö T İyidir
- Department of Endocrinology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - C Demirtaş
- Department of Biochemistry, Gazi University Faculty of Medicine, Ankara, Turkey
| | - E Suyanı
- Department of Hematology, Gazi University Faculty of Medicine, Beşevler, Ankara, Turkey
| | - İ Yetkin
- Department of Endocrinology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - H Paşaoğlu
- Department of Biochemistry, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Ç İlhan
- Department of Hematology, Gazi University Faculty of Medicine, Beşevler, Ankara, Turkey
| | - G T Sucak
- Department of Hematology, Gazi University Faculty of Medicine, Beşevler, Ankara, Turkey
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Seo SK, Yun BH, Chon SJ, Lee YJ, Han EJ, Park JH, Cho S, Choi YS, Lee BS. Association of serum ferritin levels with metabolic syndrome and subclinical coronary atherosclerosis in postmenopausal Korean women. Clin Chim Acta 2015; 438:62-6. [DOI: 10.1016/j.cca.2014.07.042] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Revised: 06/10/2014] [Accepted: 07/29/2014] [Indexed: 10/24/2022]
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Shin KA. Prevalence of Metabolic Syndrome according to Menopausal Status: The 5th Korea National Health & Nutrition Examination Survey. KOREAN JOURNAL OF CLINICAL LABORATORY SCIENCE 2014. [DOI: 10.15324/kjcls.2014.46.3.85] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Affiliation(s)
- Kyung-A Shin
- Department of Clinical Laboratory Science, Shinsung University, Dangjin 343-861, Korea
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Current world literature. Curr Opin Obstet Gynecol 2012; 24:470-8. [PMID: 23154665 DOI: 10.1097/gco.0b013e32835ae910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Dacks PA. Estrogens iron out the details: a novel direct pathway for estrogen control of iron homeostasis. Endocrinology 2012; 153:2942-4. [PMID: 22730281 DOI: 10.1210/en.2012-1480] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Penny A Dacks
- Alzheimer's Drug Discovery Foundation, 57 West 57th Street, Suite 904, New York, New York 10019, USA.
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Kim C, Nan B, Kong S, Harlow S. Changes in iron measures over menopause and associations with insulin resistance. J Womens Health (Larchmt) 2012; 21:872-7. [PMID: 22731657 DOI: 10.1089/jwh.2012.3549] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES No longitudinal studies have examined how iron measures change over menopause. Our objectives were to examine iron measures in individual women at premenopause and at postmenopause and, secondarily, to determine if any changes contributed to insulin resistance. METHODS In a subset of participants (n=70) in a longitudinal study of menopause, we measured ferritin, transferrin, and soluble transferrin receptor (sTfR) once in the premenopause and once in the postmenopause. We also examined associations between menopausal status and change in iron markers after adjustment for age at menopause, race/ethnicity, and waist circumference. In linear regression models, we examined associations between premenopause iron measures and changes in iron markers over menopause with homeostasis model assessment of insulin resistance (HOMA-IR) changes over menopause, before and after adjustment for age at menopause, race/ethnicity, changes in waist circumference, C-reactive protein (CRP), and sex hormone-binding globulin (SHBG) levels. RESULTS Women had lower ferritin (p<0.01), higher sTfR:ferritin levels (p<0.01), lower HOMA-IR (p=0.022), and lower glucose (p=0.05) in premenopause compared to postmenopause. After adjustment, lower premenopausal iron levels (sTfR:ferritin levels β=11.0, 95% confidence interval [CI] 0.017-22.0) and larger increases in iron over menopause (changes in sTfR:ferritin β=13.6, 95% CI 0.93-26.3) were associated with larger increases in HOMA-IR. CONCLUSIONS From premenopause to postmenopause, women on average have increases in measures of iron stores. Women who had the greatest changes in iron over menopause (lower measures of premenopausal iron and greater increases in iron measures over the menopause) had the strongest associations between changes in iron and changes in insulin resistance.
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Affiliation(s)
- Catherine Kim
- Department of Medicine, Obstetrics & Gynecology, University of Michigan, Ann Arbor, Michigan 48109-5429, USA.
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Houschyar KS, Lüdtke R, Dobos GJ, Kalus U, Broecker-Preuss M, Rampp T, Brinkhaus B, Michalsen A. Effects of phlebotomy-induced reduction of body iron stores on metabolic syndrome: results from a randomized clinical trial. BMC Med 2012; 10:54. [PMID: 22647517 PMCID: PMC3386865 DOI: 10.1186/1741-7015-10-54] [Citation(s) in RCA: 114] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2011] [Accepted: 05/30/2012] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Metabolic syndrome (METS) is an increasingly prevalent but poorly understood clinical condition characterized by insulin resistance, glucose intolerance, dyslipidemia, hypertension, and obesity. Increased oxidative stress catalyzed by accumulation of iron in excess of physiologic requirements has been implicated in the pathogenesis of METS, but the relationships between cause and effect remain uncertain. We tested the hypothesis that phlebotomy-induced reduction of body iron stores would alter the clinical presentation of METS, using a randomized trial. METHODS In a randomized, controlled, single-blind clinical trial, 64 patients with METS were randomly assigned to iron reduction by phlebotomy (n = 33) or to a control group (n = 31), which was offered phlebotomy at the end of the study (waiting-list design). The iron-reduction patients had 300 ml of blood removed at entry and between 250 and 500 ml removed after 4 weeks, depending on ferritin levels at study entry. Primary outcomes were change in systolic blood pressure (SBP) and insulin sensitivity as measured by Homeostatic Model Assessment (HOMA) index after 6 weeks. Secondary outcomes included HbA1c, plasma glucose, blood lipids, and heart rate (HR). RESULTS SBP decreased from 148.5 ± 12.3 mmHg to 130.5 ± 11.8 mmHg in the phlebotomy group, and from 144.7 ± 14.4 mmHg to 143.8 ± 11.9 mmHg in the control group (difference -16.6 mmHg; 95% CI -20.7 to -12.5; P < 0.001). No significant effect on HOMA index was seen. With regard to secondary outcomes, blood glucose, HbA1c, low-density lipoprotein/high-density lipoprotein ratio, and HR were significantly decreased by phlebotomy. Changes in BP and HOMA index correlated with ferritin reduction. CONCLUSIONS In patients with METS, phlebotomy, with consecutive reduction of body iron stores, lowered BP and resulted in improvements in markers of cardiovascular risk and glycemic control. Blood donation may have beneficial effects for blood donors with METS. TRIAL REGISTRATION ClinicalTrials.gov: NCT01328210 Please see related article: http://www.biomedcentral.com/1741-7015/10/53.
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Affiliation(s)
- Khosrow S Houschyar
- Department of Internal Medicine, Kliniken Essen-Mitte, University Duisburg-Essen, Essen, Germany
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Cho SH. Serum Ferritin and Metabolic Syndrome in Perimenopausal and Postmenopausal Women. ACTA ACUST UNITED AC 2011. [DOI: 10.6118/jksm.2011.17.3.166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Soo Hyun Cho
- Department of Family Medicine, College of Medicine, Chung-Ang University, Seoul, Korea
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