1
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Siracusa F, Schaltenberg N, Kumar Y, Lesker TR, Steglich B, Liwinski T, Cortesi F, Frommann L, Diercks BP, Bönisch F, Fischer AW, Scognamiglio P, Pauly MJ, Casar C, Cohen Y, Pelczar P, Agalioti T, Delfs F, Worthmann A, Wahib R, Jagemann B, Mittrücker HW, Kretz O, Guse AH, Izbicki JR, Lassen KG, Strowig T, Schweizer M, Villablanca EJ, Elinav E, Huber S, Heeren J, Gagliani N. Short-term dietary changes can result in mucosal and systemic immune depression. Nat Immunol 2023; 24:1473-1486. [PMID: 37580603 PMCID: PMC10457203 DOI: 10.1038/s41590-023-01587-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 07/13/2023] [Indexed: 08/16/2023]
Abstract
Omnivorous animals, including mice and humans, tend to prefer energy-dense nutrients rich in fat over plant-based diets, especially for short periods of time, but the health consequences of this short-term consumption of energy-dense nutrients are unclear. Here, we show that short-term reiterative switching to 'feast diets', mimicking our social eating behavior, breaches the potential buffering effect of the intestinal microbiota and reorganizes the immunological architecture of mucosa-associated lymphoid tissues. The first dietary switch was sufficient to induce transient mucosal immune depression and suppress systemic immunity, leading to higher susceptibility to Salmonella enterica serovar Typhimurium and Listeria monocytogenes infections. The ability to respond to antigenic challenges with a model antigen was also impaired. These observations could be explained by a reduction of CD4+ T cell metabolic fitness and cytokine production due to impaired mTOR activity in response to reduced microbial provision of fiber metabolites. Reintroducing dietary fiber rewired T cell metabolism and restored mucosal and systemic CD4+ T cell functions and immunity. Finally, dietary intervention with human volunteers confirmed the effect of short-term dietary switches on human CD4+ T cell functionality. Therefore, short-term nutritional changes cause a transient depression of mucosal and systemic immunity, creating a window of opportunity for pathogenic infection.
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Affiliation(s)
- Francesco Siracusa
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Nicola Schaltenberg
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Biochemistry and Molecular Cell Biology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Yogesh Kumar
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Till R Lesker
- Department of Microbial Immune Regulation, Helmholtz Centre for Infection Research, Braunschweig, Germany
| | - Babett Steglich
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Timur Liwinski
- Systems Immunology Department, Weizmann Institute of Science, Rehovot, Israel
- University Psychiatric Clinics, University of Basel, Basel, Switzerland
| | - Filippo Cortesi
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Laura Frommann
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Björn-Phillip Diercks
- Department of Biochemistry and Molecular Cell Biology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Friedericke Bönisch
- Department of Biochemistry and Molecular Cell Biology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alexander W Fischer
- Department of Biochemistry and Molecular Cell Biology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Pasquale Scognamiglio
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mira J Pauly
- Department of Biochemistry and Molecular Cell Biology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Casar
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Bioinformatics Core, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Yotam Cohen
- Systems Immunology Department, Weizmann Institute of Science, Rehovot, Israel
| | - Penelope Pelczar
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Theodora Agalioti
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Flemming Delfs
- Core Facility of Electron Microscopy, Center for Molecular Neurobiology ZMNH, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anna Worthmann
- Department of Biochemistry and Molecular Cell Biology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ramez Wahib
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bettina Jagemann
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Institute for Health Service Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hans-Willi Mittrücker
- Institute for Immunology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Oliver Kretz
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas H Guse
- Department of Biochemistry and Molecular Cell Biology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob R Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kara G Lassen
- Immunology, Infectious Diseases and Ophthalmology (I2O) Discovery and Translational Area, Roche Innovation Center, Basel, Switzerland
| | - Till Strowig
- Department of Microbial Immune Regulation, Helmholtz Centre for Infection Research, Braunschweig, Germany
- Centre for Individualised Infection Medicine (CiiM), a joint venture between the Helmholtz-Centre for Infection Research (HZI) and the Hannover Medical School (MHH), Hannover, Germany
| | - Michaela Schweizer
- Core Facility of Electron Microscopy, Center for Molecular Neurobiology ZMNH, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Eduardo J Villablanca
- Immunology and Allergy Unit, Department of Medicine, Solna, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
| | - Eran Elinav
- Systems Immunology Department, Weizmann Institute of Science, Rehovot, Israel
- Division of Microbiome and Cancer, Deutsches Krebsforschungszentrum (DKFZ), Heidelberg, Germany
| | - Samuel Huber
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Hamburg Center for Translational Immunology (HCTI), Hamburg, Germany
| | - Joerg Heeren
- Department of Biochemistry and Molecular Cell Biology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nicola Gagliani
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
- Immunology and Allergy Unit, Department of Medicine, Solna, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden.
- Hamburg Center for Translational Immunology (HCTI), Hamburg, Germany.
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2
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Lieske B, Moszka N, Borof K, Petersen EL, Jagemann B, Ebinghaus M, Beikler T, Heydecke G, Aarabi G, Zyriax BC. Association between an Anti-Inflammatory Dietary Score and Periodontitis-Evidence from the Population-Based Hamburg City Health Study. Nutrients 2023; 15:3235. [PMID: 37513653 PMCID: PMC10386141 DOI: 10.3390/nu15143235] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 07/18/2023] [Accepted: 07/19/2023] [Indexed: 07/30/2023] Open
Abstract
While the effects of dietary patterns on cardiovascular risk and diabetes have been well studied, the evidence is scarce as to which diet has the greatest anti-inflammatory potential and how dietary patterns are associated with periodontitis. In the Hamburg City Health Study (HCHS), we developed an anti-inflammatory dietary score using a data-driven approach based on the relationship of relevant selected food groups with inflammatory biomarkers (hsCRP and IL-6). The aim of this cross-sectional study was to evaluate the association between the anti-inflammatory dietary score and the incidence of periodontitis in Hamburg, Germany. A total of n = 5642 participants fit the required inclusion criteria and were selected for analysis. Periodontal disease was assessed using probing depth, gingival recession, and bleeding on probing. Dietary intake was measured using a food frequency questionnaire (FFQ). A self-developed anti-inflammatory dietary score served as the key explanatory variable. Higher scores reflected lower inflammatory processes (measured through the biomarkers hsCRP and IL-6). Several covariates were included in the regression analysis. Regressions revealed that a higher anti-inflammatory dietary score was significantly associated with lower odds to be affected by periodontal disease in an unadjusted model (OR 0.86, 95% CI 0.82-0.89, p < 0.001) and in an adjusted model (age, sex, smoking, diabetes, hypertension, and physical activity) (OR 0.93, 95% CI 0.89-0.98, p = 0.003). Our study demonstrated a significant inverse association between an anti-inflammatory dietary score and periodontitis. Individuals with higher intake of proinflammatory nutrition should be specifically addressed to avoid periodontitis.
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Affiliation(s)
- Berit Lieske
- Department of Periodontics, Preventive and Restorative Dentistry, Center for Dental and Oral Medicine, University Medical Center Hamburg Eppendorf, 20246 Hamburg, Germany
- Midwifery Science-Health Care Research and Prevention, Research Group Preventive Medicine and Nutrition, Institute for Health Service Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Nina Moszka
- Department of Periodontics, Preventive and Restorative Dentistry, Center for Dental and Oral Medicine, University Medical Center Hamburg Eppendorf, 20246 Hamburg, Germany
| | - Katrin Borof
- Department of Periodontics, Preventive and Restorative Dentistry, Center for Dental and Oral Medicine, University Medical Center Hamburg Eppendorf, 20246 Hamburg, Germany
| | - Elina Larissa Petersen
- Population Health Research Department, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Bettina Jagemann
- Midwifery Science-Health Care Research and Prevention, Research Group Preventive Medicine and Nutrition, Institute for Health Service Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Merle Ebinghaus
- Midwifery Science-Health Care Research and Prevention, Research Group Preventive Medicine and Nutrition, Institute for Health Service Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Thomas Beikler
- Department of Periodontics, Preventive and Restorative Dentistry, Center for Dental and Oral Medicine, University Medical Center Hamburg Eppendorf, 20246 Hamburg, Germany
| | - Guido Heydecke
- Department of Prosthetic Dentistry, Center for Dental and Oral Medicine, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Ghazal Aarabi
- Department of Periodontics, Preventive and Restorative Dentistry, Center for Dental and Oral Medicine, University Medical Center Hamburg Eppendorf, 20246 Hamburg, Germany
| | - Birgit-Christiane Zyriax
- Midwifery Science-Health Care Research and Prevention, Research Group Preventive Medicine and Nutrition, Institute for Health Service Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
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3
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Liwinski T, Hübener S, Henze L, Hübener P, Heinemann M, Tetzlaff M, Hiller MI, Jagemann B, Surabattula R, Leeming D, Karsdal M, Monguzzi E, Schachschal G, Rösch T, Bang C, Franke A, Lohse AW, Schuppan D, Schramm C. A prospective pilot study of a gluten-free diet for primary sclerosing cholangitis and associated colitis. Aliment Pharmacol Ther 2023; 57:224-236. [PMID: 36266939 DOI: 10.1111/apt.17256] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 04/02/2022] [Accepted: 10/08/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND Primary sclerosing cholangitis (PSC) is a progressive bile duct disease associated with inflammatory bowel disease (PSC-IBD). AIM To investigate whether patients with PSC-IBD benefit from a gluten-free and amylase trypsin inhibitor (ATI)-free diet (GFD). METHODS We performed a prospective clinical pilot study administering an eight-week GFD. The primary outcomes were colonic inflammation assessed by proctosigmoidoscopy, and liver stiffness (surrogate for fibrosis, inflammation and cholestasis) measured by transient elastography before and after GFD. Amongst the secondary (exploratory) outcomes were colonic mucosal and serum cytokine/chemokine changes, the intestinal microbiome and transcriptome dynamics, and shifts in serum markers of hepatic fibrogenesis. RESULTS Fifteen patients with PSC-IBD completed the study. The study did not meet its primary outcome: the endoscopic score and liver stiffness remained unchanged. However, the expression of pro-inflammatory mucosal cytokines and chemokines such as IL6, IL8, CCL2, and TNFα was significantly down-regulated. Two critical markers of liver fibrosis and matrix remodelling, thrombospondin-2 and -4, decreased significantly. The microbiota composition changed slightly, including a decrease in the pathogen Romboutsia ilealis. The intestinal transcriptome indicated a gut barrier improvement. Pruritus, fatigue, overall well-being, faecal calprotectin levels, and serum alkaline phosphatase did not change significantly. CONCLUSIONS This study did not demonstrate a clinical improvement with short-term GFD in patients with PSC-IBD. However, a gluten/ATI-free diet may improve biomarkers of intestinal inflammation and barrier function in these patients with associated changes in the enteric microbiota. Further investigation of the therapeutic potential of the GFD in PSC-IBD is warranted.
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Affiliation(s)
- Timur Liwinski
- Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Center for Affective, Stress and Sleep Disorders (ZASS), University Psychiatric Clinics (UPK) Basel, University of Basel, Basel, Switzerland
| | - Sina Hübener
- Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lara Henze
- Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Hübener
- Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Melina Heinemann
- Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marcus Tetzlaff
- Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marie I Hiller
- Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bettina Jagemann
- Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rambabu Surabattula
- Institute of Translational Immunology and Research Center for Immunotherapy, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Diana Leeming
- Research and Development, Nordic Bioscience, Biomarkers and Research A/S, Herlev, Denmark
| | - Morten Karsdal
- Research and Development, Nordic Bioscience, Biomarkers and Research A/S, Herlev, Denmark
| | - Erika Monguzzi
- Institute of Translational Immunology and Research Center for Immunotherapy, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Guido Schachschal
- Department of Interdisciplinary Endoscopy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Rösch
- Department of Interdisciplinary Endoscopy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Corinna Bang
- Institute for Clinical Molecular Biology, Christian Albrechts University of Kiel, Kiel, Germany
| | - Andre Franke
- Institute for Clinical Molecular Biology, Christian Albrechts University of Kiel, Kiel, Germany
| | - Ansgar W Lohse
- Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Hamburg Center for Translational Immunology, Hamburg, Germany
| | - Detlef Schuppan
- Institute of Translational Immunology and Research Center for Immunotherapy, University Medical Center, Johannes Gutenberg University, Mainz, Germany.,Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Christoph Schramm
- Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Hamburg Center for Translational Immunology, Hamburg, Germany.,Martin Zeitz Center for Rare Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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4
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Lieske B, Makarova N, Jagemann B, Walther C, Ebinghaus M, Zyriax BC, Aarabi G. Inflammatory Response in Oral Biofilm during Pregnancy: A Systematic Review. Nutrients 2022; 14:nu14224894. [PMID: 36432584 PMCID: PMC9694722 DOI: 10.3390/nu14224894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 10/20/2022] [Accepted: 11/15/2022] [Indexed: 11/22/2022] Open
Abstract
Understanding the inflammatory response in oral biofilm during pregnancy and its association with oral and maternal health is essential for identifying biomarker patterns that may serve as markers of pregnancy-related complications. We aimed to conduct a systematic review of the available literature to assess: (1) inflammatory responses in oral biofilm during pregnancy, (2) the association between inflammatory responses in oral biofilm during pregnancy and maternal, oral or systemic conditions, (3) changes in the response of inflammatory biomarkers found in the oral biofilm during different pregnancy stages, and (4) the value of other risk factors such as nutrition and lifestyle. PubMed, Web of Science and Cochrane Library were systematically searched from inception until April 2022. From 5441 records, 39 studies were included for qualitative assessment. The oral biofilm in pregnant women was associated with increased inflammatory biomarkers when compared to non-pregnant women. Levels of inflammatory biomarkers in the oral biofilm were found to be highest in pregnant women with systemic conditions. Increased inflammatory biomarkers in the oral biofilm were also associated with worse oral health outcomes. Given the importance of nutrition and lifestyle for pregnancy and oral health outcomes and the fact that these factors were largely excluded in the included studies, future research should consider a holistic view of the mother during pregnancy to capture physiological, hormonal, immunologic, and metabolic changes in the context of inflammatory responses.
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Affiliation(s)
- Berit Lieske
- Department of Periodontics, Preventive and Restorative Dentistry, Center for Dental and Oral Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, O58, 20246 Hamburg, Germany
- Midwifery Science–Health Care Research and Prevention, Research Group Preventive Medicine and Nutrition, Institute for Health Service Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf, Martinistraße 52, W38, 20246 Hamburg, Germany
- Correspondence:
| | - Nataliya Makarova
- Midwifery Science–Health Care Research and Prevention, Research Group Preventive Medicine and Nutrition, Institute for Health Service Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf, Martinistraße 52, W38, 20246 Hamburg, Germany
| | - Bettina Jagemann
- Midwifery Science–Health Care Research and Prevention, Research Group Preventive Medicine and Nutrition, Institute for Health Service Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf, Martinistraße 52, W38, 20246 Hamburg, Germany
| | - Carolin Walther
- Department of Periodontics, Preventive and Restorative Dentistry, Center for Dental and Oral Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, O58, 20246 Hamburg, Germany
| | - Merle Ebinghaus
- Midwifery Science–Health Care Research and Prevention, Research Group Preventive Medicine and Nutrition, Institute for Health Service Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf, Martinistraße 52, W38, 20246 Hamburg, Germany
| | - Birgit-Christiane Zyriax
- Midwifery Science–Health Care Research and Prevention, Research Group Preventive Medicine and Nutrition, Institute for Health Service Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf, Martinistraße 52, W38, 20246 Hamburg, Germany
| | - Ghazal Aarabi
- Department of Periodontics, Preventive and Restorative Dentistry, Center for Dental and Oral Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, O58, 20246 Hamburg, Germany
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5
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Wolbert L, Kreutzburg T, Zyriax BC, Adegbola A, Westenhöfer J, Jagemann B, Alexander Neumann F, Preuß M, Debus ES, Rieß HC, Behrendt CA. A cross-sectional survey study on the nutrition patterns of patients with peripheral artery disease. VASA 2022; 51:239-246. [PMID: 35499268 DOI: 10.1024/0301-1526/a001005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background: Even though nutrition was demonstrated to have an impact on chronic atherosclerotic disease, there is a paucity of corresponding recommendations for patients with peripheral artery disease (PAD). A Mediterranean Diet based on daily intake of fruits and vegetables with high fibre, vegetable oil, and unsalted nuts including fish several times a week may have protective effects. This cross-sectional survey aimed to determine nutritional patterns amongst inpatients with PAD. Methods: All inpatients with symptomatic PAD who underwent revascularisation at a single centre between 1st May 2018 and 31st December 2021 were asked to fill out a questionnaire on nutritional intake. An 8-item frequency rating scale (from never to three times a day) was used for 15 food groups. For 11 of them, an adapted Mediterranean Diet score was calculated using the answers. The descriptive results were stratified by sex and disease stage (intermittent claudication vs. chronic limb-threatening ischaemia). Results: A total of 319 patients (31.7% female, 69.4 years in mean) were included. Thereof, 71.8% reported they did never receive any nutritional information considering their PAD disease. The mean adapted Mediterranean Diet score was 2.7 points (of maximum 11) with most patients not achieving the recommended servings per week for fruits (1.6%), vegetables (1.0%), and unsalted nuts (12.2%). The intake of cereals was sufficient (43.3%). When compared with men, women consumed more fruits and less meat. Conclusions: This survey demonstrated that although healthy nutrition may have a positive impact on patients with PAD, the education and adherence to a Mediterranean Diet was inappropriate. Nutritional patterns should be more focused in future PAD studies to derive specific recommendations and nutritional programmes as well as patient education in clinical practice.
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Affiliation(s)
- Lara Wolbert
- Research Group GermanVasc, Department of Vascular Medicine, University Heart and Vascular Centre UKE Hamburg, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.,The first two authors contributed equally
| | - Thea Kreutzburg
- Research Group GermanVasc, Department of Vascular Medicine, University Heart and Vascular Centre UKE Hamburg, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.,The first two authors contributed equally
| | - Birgit-Christiane Zyriax
- Midwifery Science - Health Care Research and Prevention, Institute for Health Services Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Abiodun Adegbola
- Research Group GermanVasc, Department of Vascular Medicine, University Heart and Vascular Centre UKE Hamburg, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Joachim Westenhöfer
- Competence Center Health, Faculty of Life Sciences, University of Applied Sciences (HAW), Hamburg, Germany
| | - Bettina Jagemann
- Midwifery Science - Health Care Research and Prevention, Institute for Health Services Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Felix Alexander Neumann
- Midwifery Science - Health Care Research and Prevention, Institute for Health Services Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mark Preuß
- Research Group GermanVasc, Department of Vascular Medicine, University Heart and Vascular Centre UKE Hamburg, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - E Sebastian Debus
- Research Group GermanVasc, Department of Vascular Medicine, University Heart and Vascular Centre UKE Hamburg, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Henrik C Rieß
- Research Group GermanVasc, Department of Vascular Medicine, University Heart and Vascular Centre UKE Hamburg, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Christian-Alexander Behrendt
- Research Group GermanVasc, Department of Vascular Medicine, University Heart and Vascular Centre UKE Hamburg, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.,Brandenburg Medical School Theodor Fontane, Neuruppin, Germany
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6
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Altun E, Walther C, Borof K, Petersen E, Lieske B, Kasapoudis D, Jalilvand N, Beikler T, Jagemann B, Zyriax BC, Aarabi G. Association between Dietary Pattern and Periodontitis-A Cross-Sectional Study. Nutrients 2021; 13:nu13114167. [PMID: 34836422 PMCID: PMC8621734 DOI: 10.3390/nu13114167] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 11/18/2021] [Accepted: 11/19/2021] [Indexed: 02/06/2023] Open
Abstract
The aim of the study was to investigate the relationship between specific known dietary patterns and the prevalence of periodontal disease in a northern population-based cohort study. We evaluated data from 6209 participants of the Hamburg City Health Study (HCHS). The HCHS is a prospective cohort study and is registered at ClinicalTrial.gov (NCT03934957). Dietary intake was assessed with the food frequency questionnaire (FFQ2). Periodontal examination included probing depth, gingival recession, plaque index, and bleeding on probing. Descriptive analyses were stratified by periodontitis severity. Ordinal logistic regression models were used to determine the association. Ordinal regression analyses revealed a significant association between higher adherence to the DASH diet/Mediterranean diet and lower odds to be affected by periodontal diseases in an unadjusted model (OR: 0.92; 95% CI: 0.87, 0.97; p < 0.001/OR: 0.93; 95% CI: 0.91, 0.96; p < 0.001) and an adjusted model (age, sex, diabetes) (OR: 0.94; 95% CI: 0.89, 1.00; p < 0.0365/OR: 0.97; 95% CI: 0.94, 1.00; p < 0.0359). The current cross-sectional study identified a significant association between higher adherence to the DASH and Mediterranean diets and lower odds to be affected by periodontal diseases (irrespective of disease severity). Future randomized controlled trials are needed to evaluate to which extent macro- and micronutrition can affect periodontitis initiation/progression.
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Affiliation(s)
- Ersin Altun
- Department of Periodontics, Preventive and Restorative Dentistry, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany; (E.A.); (K.B.); (B.L.); (D.K.); (N.J.); (T.B.); (G.A.)
| | - Carolin Walther
- Department of Periodontics, Preventive and Restorative Dentistry, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany; (E.A.); (K.B.); (B.L.); (D.K.); (N.J.); (T.B.); (G.A.)
- Correspondence: ; Tel.: +49-40-7410-52284
| | - Katrin Borof
- Department of Periodontics, Preventive and Restorative Dentistry, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany; (E.A.); (K.B.); (B.L.); (D.K.); (N.J.); (T.B.); (G.A.)
| | - Elina Petersen
- Department of Cardiology, University Heart and Vascular Center, 20246 Hamburg, Germany;
- Population Health Research Department, University Heart and Vascular Center, 20246 Hamburg, Germany
| | - Berit Lieske
- Department of Periodontics, Preventive and Restorative Dentistry, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany; (E.A.); (K.B.); (B.L.); (D.K.); (N.J.); (T.B.); (G.A.)
| | - Dimitros Kasapoudis
- Department of Periodontics, Preventive and Restorative Dentistry, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany; (E.A.); (K.B.); (B.L.); (D.K.); (N.J.); (T.B.); (G.A.)
| | - Navid Jalilvand
- Department of Periodontics, Preventive and Restorative Dentistry, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany; (E.A.); (K.B.); (B.L.); (D.K.); (N.J.); (T.B.); (G.A.)
| | - Thomas Beikler
- Department of Periodontics, Preventive and Restorative Dentistry, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany; (E.A.); (K.B.); (B.L.); (D.K.); (N.J.); (T.B.); (G.A.)
| | - Bettina Jagemann
- Midwifery Science—Health Services Research and Prevention, Institute for Health Services Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf (UKE), 20246 Hamburg, Germany; (B.J.); (B.-C.Z.)
| | - Birgit-Christiane Zyriax
- Midwifery Science—Health Services Research and Prevention, Institute for Health Services Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf (UKE), 20246 Hamburg, Germany; (B.J.); (B.-C.Z.)
| | - Ghazal Aarabi
- Department of Periodontics, Preventive and Restorative Dentistry, University Medical Centre Hamburg-Eppendorf, 20246 Hamburg, Germany; (E.A.); (K.B.); (B.L.); (D.K.); (N.J.); (T.B.); (G.A.)
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von Katzler R, Zyriax BC, Jagemann B, Westenhoefer J, Jensen HJ, Harth V, Oldenburg M. Lifestyle behaviour and prevalence of cardiovascular risk factors - a pilot study comparing Kiribati and European seafarers. BMC Public Health 2019; 19:855. [PMID: 31262273 PMCID: PMC6604182 DOI: 10.1186/s12889-019-7186-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 06/17/2019] [Indexed: 12/17/2022] Open
Abstract
Background According to internal observations within a German shipping company, obvious risk-behaviour persists among the crew members coming from the Pacific Island State of Kiribati and representing a large part of the crew aboard merchant vessels of this company. These observations were related to excessive eating habits. This study aims to assess the cardiovascular risk among seafarers and to compare lifestyle factors between Kiribati and European crew members. Methods In the present maritime field study 81 sailors (48 Kiribati, 33 European, average age at 38.9 and 36.8 years respectively) were examined from April until August 2014 aboard four container ships crossing the Atlantic Ocean (participation rate of 90.9%). Results Based on the number of established risk factors, 35.4% of the Kiribati and 16.7% of the European crew members were regarded as a high risk group for cardiovascular diseases. The HDL-values of Kiribati were found to be considerably lower (34.9 mg/dl) than the references values given by the WHO and in comparison to the European crew members (44.8 mg/dl) (p = 0.002). 91.7% of Kiribati and 51.5% of European participants were found to be overweight according to WHO-criteria - with a mean Body Mass Index (BMI) of 30.3 kg/m2 and 25.6 kg/m2 (p < 0.001). Regarding lifestyle factors Kiribati often claimed to eat significantly larger amounts of food aboard while most European sailors stated to eat less or about the same during their shipboard stay (p = 0.017). Daily sleeping hours were slight on both sides; however with a mean of 5.2 h a day Kiribati crew members had significant fewer sleep (p = 0.038). The examined Kiribati sailors had a mean increase in weight of 6 kg over a 12 months period of observation. Conclusions In total the compiled data points towards a higher risk of cardiovascular diseases particularly due to alimentary habits within the Kiribati crew members. The distinct weight-gain measured among the Kiribati in spite of higher energy consumption levels at sea is alarming. Thus, the results of this study confirm the necessity of health-improving interventions aboard cargo vessels.
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Affiliation(s)
- R von Katzler
- Institute for Occupational and Maritime Medicine (ZfAM) Hamburg, Seewartenstr, 10, 20459, Hamburg, Germany.
| | - B C Zyriax
- Preventive Medicine and Nutrition, Institute for Health Services Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - B Jagemann
- Medical Clinic and Polyclinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - J Westenhoefer
- Competence Center Health, Faculty of Life Sciences, Hamburg University of Applied Sciences, Hamburg, Germany
| | - H J Jensen
- Institute for Occupational and Maritime Medicine (ZfAM) Hamburg, Seewartenstr, 10, 20459, Hamburg, Germany
| | - V Harth
- Institute for Occupational and Maritime Medicine (ZfAM) Hamburg, Seewartenstr, 10, 20459, Hamburg, Germany
| | - M Oldenburg
- Institute for Occupational and Maritime Medicine (ZfAM) Hamburg, Seewartenstr, 10, 20459, Hamburg, Germany.
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Zyriax BC, von Katzler R, Jagemann B, Westenhoefer J, Jensen HJ, Harth V, Oldenburg M. Food offerings on board and dietary intake of European and Kiribati seafarers - cross-sectional data from the seafarer nutrition study. J Occup Med Toxicol 2018; 13:9. [PMID: 29988947 PMCID: PMC6034640 DOI: 10.1186/s12995-018-0190-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 02/20/2018] [Indexed: 12/17/2022] Open
Abstract
Background Overweight and cardiovascular risk factors are a common phenomenon in seafarers. According to internal observation particularly crew members from the Pacific Island State of Kiribati are exposed to a high risk. However, in mixed crews, cultural background plays an important role, influencing food choice, and the actual risk. Methods The Seafarer Nutrition Study (SeaNut study) compared dietary factors in 48 Kiribati and 33 European male seafarers recruited from four merchant ships with a high level of Kiribati manning within a German shipping company. Analysis encompassed the assessment of dietary quality on board, satisfaction with prepared dishes, and individual food intake obtained from 24-h recalls in comparison with nutritional recommendations. Results The overall supply of meat, fat and eggs was more than double, whereas the proportions of fruits, vegetables, dairy products and cereals were much lower than recommended. Based on the reported food choices, both groups, but notably Kiribati seafarers, did not reach reference values as to macronutrient, micronutrient and fiber intake. In addition, satisfaction with the meals served, food preferences and knowledge about a healthy diet varied markedly between Kiribati and Europeans. Conclusions The present analysis of the SeaNut study revealed the necessity of future health intervention programs, including the quality of the food supply as well as information about a healthy diet and adequate food selection. In mixed crews, culture-specific differences should be considered, in order to facilitate the long-term success of interventions. Trial registration German Clinical Trials Registry DRKS00010819 retrospectively. Registered 18 July 2016 (www.germanctr.de).
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Affiliation(s)
- Birgit-Christiane Zyriax
- 1Preventive Medicine and Nutrition, Institute for Health Services Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf, Martinistr. 52 - Bldg. O56 - D-20246, Hamburg, Germany
| | - Robert von Katzler
- 2Department of Maritime Medicine, Institute for Occupational and Maritime Medicine (ZfAM) Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bettina Jagemann
- 3I. Medical Clinic and Polyclinic; University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Joachim Westenhoefer
- 4Competence Center Health, Faculty of Life Sciences, Hamburg University of Applied Sciences, Hamburg, Germany
| | - Hans-Joachim Jensen
- 2Department of Maritime Medicine, Institute for Occupational and Maritime Medicine (ZfAM) Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Volker Harth
- 2Department of Maritime Medicine, Institute for Occupational and Maritime Medicine (ZfAM) Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marcus Oldenburg
- 2Department of Maritime Medicine, Institute for Occupational and Maritime Medicine (ZfAM) Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Westenhoefer J, von Katzler R, Jensen HJ, Zyriax BC, Jagemann B, Harth V, Oldenburg M. Cultural differences in food and shape related attitudes and eating behavior are associated with differences of Body Mass Index in the same food environment: cross-sectional results from the Seafarer Nutrition Study of Kiribati and European seafarers on merchant ships. BMC Obes 2018; 5:1. [PMID: 29416869 PMCID: PMC5784660 DOI: 10.1186/s40608-018-0180-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 01/11/2018] [Indexed: 12/02/2022]
Abstract
Background Overweight and obesity is quite prevalent among seafarers. The present study examined differences in BMI and their association with weight, shape and nutrition related attitudes and perceptions among seafarer from Kiribati, a Pacific Island Group, and European origin. Methods The Seafarer Nutrition Study compared 48 Kiribati and 33 European male seafarers from 4 commercial merchant ships. BMI was calculated from measured weight and height. Attitudes to weight, shape and nutrition and disinhibition of control as a characteristic of eating behavior were assessed in a structured interview. Differences between the two groups were examined using t-tests and Chi-square-tests as appropriate. Associations between the variables were examined using Multiple Regression Analysis (MRA) and correlations. Results Kiribati seafarer had significantly higher BMI than Europeans (30.3 ± 4.2 vs. 25.6 ± 3.4; p < 0.001). However, MRA indicated that Kiribati were choosing thinner shapes as being “most similar” to their appearance than Europeans with the same BMI (B = − 1.14; p < 0.05). In addition, Kiribati had significantly higher scores of disinhibition than Europeans (5.6 ± 2.2 vs. 4.3 ± 2.1; p < 0.01), and disinhibition correlated with BMI in the Kiribati (r = 0.39; p < 0.01), but not in the European group (r = 0.17; n.s.). Conclusions For Kiribati seafarers the nutrition situation on board represents a highly tempting westernized food environment. Their tendency to disinhibited eating facilitates overconsumption and weight gain, and self-evaluation of their shapes as being thinner than comparable Europeans may hamper appropriate weight control behavior.
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Affiliation(s)
- Joachim Westenhoefer
- 1Competence Center Health, Department Health Sciences, Hamburg University of Applied Science, Ulmenliet 20, 21033 Hamburg, Germany
| | - Robert von Katzler
- 2Institute for Occupational and Maritime Medicine (ZfAM) Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hans-Joachim Jensen
- 2Institute for Occupational and Maritime Medicine (ZfAM) Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Birgit-Christiane Zyriax
- 3Preventive Medicine and Nutrition, Institute for Health Services Research in Dermatology and Nursing (IVDP), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bettina Jagemann
- 4I. Medical Clinic and Polyclinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Volker Harth
- 2Institute for Occupational and Maritime Medicine (ZfAM) Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marcus Oldenburg
- 2Institute for Occupational and Maritime Medicine (ZfAM) Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Wehmeyer MH, Zyriax BC, Jagemann B, Roth E, Windler E, Schulze zur Wiesch J, Lohse AW, Kluwe J. Nonalcoholic fatty liver disease is associated with excessive calorie intake rather than a distinctive dietary pattern. Medicine (Baltimore) 2016; 95:e3887. [PMID: 27281105 PMCID: PMC4907683 DOI: 10.1097/md.0000000000003887] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
We aimed to assess the dietary patterns associated with nonalcoholic fatty liver disease (NAFLD) and the efficacy of dietary interventions in a real-life setting at a tertiary medical center in Northern Germany.Clinical and laboratory data as well as data obtained by a semiquantitative food frequency questionnaire of 55 consecutive patients diagnosed with NAFLD were compared to an age and gender-matched cohort of 88 healthy individuals by univariate analysis. The efficacy of the dietary intervention was assessed in a subgroup of 24 NAFLD patients 6 months after receiving dietary advice. Macronutritional components of the diet were normalized for absolute daily energy intake.NAFLD patients consumed more calories per day as compared with healthy controls (P <0.001). The absolute amounts of most nutritional components ingested by NAFLD patients were higher than those of the controls. However, there were no significant differences with regards to the relative consumption of carbohydrates (P = 0.359), fat (P = 0.416), and fructose (P = 0.353) per 1000 kcal energy intake. NAFLD patients displayed a higher intake of glucose/1000 kcal (P = 0.041) and protein/1000 kcal (P = 0.009) but a lower intake of fibers/1000 kcal (P < 0.001) and mineral nutrients/1000 kcal (P = 0.001) than healthy controls. In the longitudinal analysis patients significantly reduced their caloric intake and their ALT levels improved 6 months after the dietary counselling (P < 0.001).Our data from a German real-life cohort demonstrate that dietary patterns of patients with NAFLD display great variability and little disease specificity, while the most distinctive feature compared with healthy controls was higher energy intake in NAFLD patients.
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Affiliation(s)
- Malte H. Wehmeyer
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Birgit-Christiane Zyriax
- Preventive Medicine, Department of General and Interventional Cardiology, Hamburg University Heart Center, Hamburg, Germany
| | - Bettina Jagemann
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ewgenia Roth
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Eberhard Windler
- Preventive Medicine, Department of General and Interventional Cardiology, Hamburg University Heart Center, Hamburg, Germany
| | | | - Ansgar W. Lohse
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Johannes Kluwe
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- ∗Correspondence to Johannes Kluwe, I. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany (e-mail: )
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Herkel J, Jagemann B, Wiegard C, Lazaro JFG, Lueth S, Kanzler S, Blessing M, Schmitt E, Lohse AW. MHC class II-expressing hepatocytes function as antigen-presenting cells and activate specific CD4 T lymphocyutes. Hepatology 2003; 37:1079-85. [PMID: 12717388 DOI: 10.1053/jhep.2003.50191] [Citation(s) in RCA: 109] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The ability to activate CD4 T cells is restricted to antigen-presenting cells that express major histocompatibility complex (MHC) class II molecules. Parenchymal cells normally do not express MHC class II molecules; however, in clinical hepatitis, viral or autoimmune, hepatocytes often exhibit aberrant MHC class II expression. It is not known whether MHC class II-expressing hepatocytes can function as antigen-presenting cells, but it has been suggested that aberrant MHC class II expression by parenchymal cells may cause autoimmune disease. Therefore, we generated transgenic mice that specifically overexpress class II transactivator molecules in hepatocytes. Hepatocytes from these mice exhibited stable MHC class II expression and were used to stimulate CD4 T cells from T-cell receptor transgenic mice and CD4 T-cell lines. MHC II-expressing hepatocytes featured costimulatory CD80 molecules and could serve as antigen-presenting cells that were able to process protein antigen and to activate specific CD4 T cells. Nevertheless, the transgenic mice with aberrant hepatocellular MHC class II expression did not exhibit any symptoms of autoimmune disease. In conclusion, MHC II-expressing hepatocytes, as found in clinical hepatitis, can present antigen and activate CD4 T cells. The ability of hepatocytes to present antigen on MHC II molecules does not seem to be a sufficient cause for inflammatory autoimmunity and hepatitis. However, we still need to explore whether such antigen presentation is occurring in vivo. The transgenic mice described in this study may serve as a model to study the immune interaction of hepatocytes and CD4 T cells in both in vitro and in vivo.
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Affiliation(s)
- Johannes Herkel
- I. Department of Medicine, Johannes Gutenberg-University, Mainz, Germany
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