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1.  Endogenous red blood cell membrane fatty acids and sudden cardiac arrest 
Little is known of the associations of endogenous fatty acids with sudden cardiac arrest (SCA). We investigated the associations of SCA with red blood cell membrane fatty acids that are end products of de novo fatty acid synthesis: myristic acid (14:0), palmitic acid (16:0), palmitoleic acid (16:1 n7), vaccenic acid (18:1 n7), stearic acid (18:0), oleic acid (18:1 n9) and a related fatty acid cis-7 hexadecenoic acid (16:1 n9). We used data from a population-based case-control study, where cases, aged 25-74 years, were out-of-hospital sudden cardiac arrest patients, attended by paramedics in Seattle, Washington (n=265). Controls, matched to cases by age, sex and calendar year, were randomly identified from the community (n=415). All participants were free of prior clinically-diagnosed heart disease. We observed associations of higher red blood cell membrane levels of 16:0, 16:1n-7, 18:1n-7 and 16:1n-9 with higher risk of SCA. In analyses adjusted for traditional SCA risk factors and trans- and n-3 fatty acids, a one-standard-deviation-higher level of 16:0 was associated with 38% higher risk of SCA (odds ratio [OR] 1.38, 95% confidence interval [CI]: 1.12-1.70) and a one-standard deviation-higher level of 16:1n-9 with 88% higher risk (OR 1.88, 95% CI: 1.27-2.78). Several fatty acids that are end products of fatty acid synthesis are associated with SCA risk. Further work is needed to investigate if conditions that favor de novo fatty acid synthesis, such as high carbohydrate/low fat diets, might also increase the risk of SCA.
doi:10.1016/j.metabol.2009.10.026
PMCID: PMC2882498  PMID: 20045147
2.  Red Blood Cell Membrane Alpha-linolenic Acid and the Risk of Sudden Cardiac Arrest 
Higher levels of long-chain n-3 polyunsaturated fatty acids in red blood cell membranes are associated with lower risk of sudden cardiac arrest. Whether membrane levels of α-linolenic acid, a medium-chain n-3 polyunsaturated fatty acid, show a similar association is unclear. We investigated the association of red blood cell membrane alpha-linolenic acid with sudden cardiac arrest risk in a population-based case-control study. Cases, aged 25–74 years, were out-of-hospital sudden cardiac arrest patients, attended by paramedics in Seattle, Washington (n=265). Controls, matched to cases by age, sex and calendar year, were randomly identified from the community (n=415). All participants were free of prior clinically-diagnosed heart disease. Blood was obtained at the time of cardiac arrest (cases) or at the time of an interview (controls). Higher membrane alpha-linolenic acid was associated with a higher risk of sudden cardiac arrest: after adjustment for matching factors and smoking, diabetes, hypertension, education, physical activity, weight, height and total fat intake, the odds ratios corresponding to increasing quartiles of alpha-linolenic acid were 1.7 (95% confidence interval [CI] 1.0–3.0), 1.9 (95% CI 1.1–3.3), and 2.5 (95% CI 1.3–4.8) compared to the lowest quartile. The association was independent of red blood cell levels of long-chain n-3 fatty acids, trans-fatty acids, and linoleic acid. Higher membrane levels of alpha-linolenic acid are associated with higher risk of sudden cardiac arrest.
doi:10.1016/j.metabol.2008.11.013
PMCID: PMC2683729  PMID: 19303975
3.  Genetic loci associated with circulating levels of very long-chain saturated fatty acids[S] 
Journal of Lipid Research  2015;56(1):176-184.
Very long-chain saturated fatty acids (VLSFAs) are saturated fatty acids with 20 or more carbons. In contrast to the more abundant saturated fatty acids, such as palmitic acid, there is growing evidence that circulating VLSFAs may have beneficial biological properties. Whether genetic factors influence circulating levels of VLSFAs is not known. We investigated the association of common genetic variation with plasma phospholipid/erythrocyte levels of three VLSFAs by performing genome-wide association studies in seven population-based cohorts comprising 10,129 subjects of European ancestry. We observed associations of circulating VLSFA concentrations with common variants in two genes, serine palmitoyl-transferase long-chain base subunit 3 (SPTLC3), a gene involved in the rate-limiting step of de novo sphingolipid synthesis, and ceramide synthase 4 (CERS4). The SPTLC3 variant at rs680379 was associated with higher arachidic acid (20:0 , P = 5.81 × 10−13). The CERS4 variant at rs2100944 was associated with higher levels of 20:0 (P = 2.65 × 10−40) and in analyses that adjusted for 20:0, with lower levels of behenic acid (P = 4.22 × 10−26) and lignoceric acid (P = 3.20 × 10−21). These novel associations suggest an inter-relationship of circulating VLSFAs and sphingolipid synthesis.
doi:10.1194/jlr.M052456
PMCID: PMC4274065  PMID: 25378659
arachidic acid; behenic acid; lignoceric acid; sphingolipids
4.  Plasma Free Fatty Acids and Risk of Heart Failure: The Cardiovascular Health Study 
Circulation. Heart failure  2013;6(5):10.1161/CIRCHEARTFAILURE.113.000521.
Background
Although plasma free fatty acid (FFA) concentrations have been associated with lipotoxicity, apoptosis, and risk of diabetes and coronary heart disease, it is unclear whether FFA levels are associated with heart failure (HF).
Methods and Results
To test the hypothesis that plasma concentration of FFA is positively associated with incident HF, we prospectively analyzed data on 4248 men and women free of HF at baseline and aged 65+ years from the Cardiovascular Health Study. FFA concentration was measured in duplicate by the Wako enzymatic method. Incident HF was validated by a centralized Events Committee. We used Cox proportional hazards to estimate the hazard ratio of HF per standard deviation (SD) of FFA. During a median follow up of 10.5 y, 1,286 new cases of HF occurred. In a multivariable model adjusting for clinic site, comorbidity, demographic, anthropometric, and lifestyle factors, each SD (0.2 mEq/L) higher plasma FFA was associated with 12% (95% CI: 6% to 19%) higher risk of HF. Controlling for time-varying diabetes and coronary heart disease did not change the results [HR per SD: 1.16 (95% CI: 1.09–1.23)].
Conclusions
A single measure of plasma FFA obtained later in life is associated with a higher risk of HF in older adults. Additional studies are needed to explore biologic mechanisms by which FFA may influence the risk of HF and determine whether FFA could serve as a novel pharmacological target for HF prevention.
doi:10.1161/CIRCHEARTFAILURE.113.000521
PMCID: PMC3884584  PMID: 23926204
heart failure; epidemiology; nutrition; free fatty acids
5.  Plasma Phospholipid Trans‐Fatty Acids Levels, Cardiovascular Diseases, and Total Mortality: The Cardiovascular Health Study 
Background
While self‐reported trans–fatty acid (TFA) consumption is linked to coronary heart disease (CHD), relationships between objective biomarkers of TFA subtypes (t‐16:1n9, total t‐18:1, and cis/trans‐(c/t‐), t/c‐ and t/t‐18:2) and cardiovascular disease (CVD) or total mortality are not well established.
Methods and Results
We evaluated 2742 adults in the Cardiovascular Health Study, aged 74±5 years and free of prevalent CVD, with plasma phospholipid TFA measures in 1992. Incident fatal and nonfatal CHD events, CVD and non‐CVD mortality, and total mortality were centrally adjudicated through 2010. Risks were assessed using Cox proportional hazards. During 31 494 person‐years, 1735 total deaths and 639 total CHD events occurred. In the multivariate model including mutual adjustment for the 5 TFA subtypes, circulating t/t‐18:2 was associated with higher total mortality (extreme quintile hazard ratio (HR)=1.23, 95% CI=1.04 to 1.44, P‐trend=0.01), CVD mortality (HR=1.40, 95% CI=1.05 to 1.86, P‐trend=0.02), and total CHD (HR=1.39, 95% CI=1.06 to 1.83, P‐trend=0.01). t/c‐18:2 was positively related to total mortality (HR=1.19, P‐trend=0.05), total CHD (HR=1.67, P‐trend=0.002), and nonfatal CHD (HR=2.06, P‐trend=0.002) after mutual adjustment; these associations were insignificant without mutual adjustment. Neither t‐16:1n9 nor t‐18:1 was significantly associated with total mortality or CVD, nor was c/t‐18:2 if we excluded early cases.
Conclusions
Among circulating TFAs, t/t‐18:2 was most adversely associated with total mortality, mainly due to the increased risk of CVD. t/c‐18:2 was also positively associated with total mortality and CHD, but only after adjustment for other TFAs. These results highlight the need for further investigation of dietary sources, nondietary determinants, and health effects of specific TFA subtypes, especially t‐18:2 isomers.
doi:10.1161/JAHA.114.000914
PMCID: PMC4310377  PMID: 25164946
cardiovascular diseases; coronary disease; nutrition; total mortality; trans–fatty acids
6.  Genome-wide meta-analysis of observational studies shows common genetic variants associated with macronutrient intake1234 
Background: Macronutrient intake varies substantially between individuals, and there is evidence that this variation is partly accounted for by genetic variants.
Objective: The objective of the study was to identify common genetic variants that are associated with macronutrient intake.
Design: We performed 2-stage genome-wide association (GWA) meta-analysis of macronutrient intake in populations of European descent. Macronutrients were assessed by using food-frequency questionnaires and analyzed as percentages of total energy consumption from total fat, protein, and carbohydrate. From the discovery GWA (n = 38,360), 35 independent loci associated with macronutrient intake at P < 5 × 10−6 were identified and taken forward to replication in 3 additional cohorts (n = 33,533) from the DietGen Consortium. For one locus, fat mass obesity-associated protein (FTO), cohorts with Illumina MetaboChip genotype data (n = 7724) provided additional replication data.
Results: A variant in the chromosome 19 locus (rs838145) was associated with higher carbohydrate (β ± SE: 0.25 ± 0.04%; P = 1.68 × 10−8) and lower fat (β ± SE: −0.21 ± 0.04%; P = 1.57 × 10−9) consumption. A candidate gene in this region, fibroblast growth factor 21 (FGF21), encodes a fibroblast growth factor involved in glucose and lipid metabolism. The variants in this locus were associated with circulating FGF21 protein concentrations (P < 0.05) but not mRNA concentrations in blood or brain. The body mass index (BMI)–increasing allele of the FTO variant (rs1421085) was associated with higher protein intake (β ± SE: 0.10 ± 0.02%; P = 9.96 × 10−10), independent of BMI (after adjustment for BMI, β ± SE: 0.08 ± 0.02%; P = 3.15 × 10−7).
Conclusion: Our results indicate that variants in genes involved in nutrient metabolism and obesity are associated with macronutrient consumption in humans. Trials related to this study were registered at clinicaltrials.gov as NCT00005131 (Atherosclerosis Risk in Communities), NCT00005133 (Cardiovascular Health Study), NCT00005136 (Family Heart Study), NCT00005121 (Framingham Heart Study), NCT00083369 (Genetic and Environmental Determinants of Triglycerides), NCT01331512 (InCHIANTI Study), and NCT00005487 (Multi-Ethnic Study of Atherosclerosis).
doi:10.3945/ajcn.112.052183
PMCID: PMC3652928  PMID: 23636237
7.  Plasma Phospholipid Saturated Fatty Acids and Incident Atrial Fibrillation: The Cardiovascular Health Study 
Background
Prior studies suggest that circulating fatty acids may influence the risk of atrial fibrillation (AF), but little is known about the associations of circulating saturated fatty acids with risk of AF.
Methods and Results
The study population included 2899 participants from the Cardiovascular Health Study, a community‐based longitudinal cohort of adults aged 65 years or older in the United States who were free of prevalent coronary heart disease and AF in 1992. Cox regression was used to assess the association of all the long‐chain saturated fatty acids—palmitic acid (16:0), stearic acid (18:0), arachidic acid (20:0), behenic acid (22:0), and lignoceric acid (24:0)—with incident AF. During a median of 11.2 years of follow‐up, 707 cases of incident AF occurred. After adjustment for other AF risk factors, higher levels of circulating 16:0 were associated with a higher risk of AF (hazard ratio comparing highest and lowest quartiles: 1.48; 95% CI: 1.18, 1.86). In contrast, higher levels of circulating 18:0, 20:0, 22:0, and 24:0 were each associated with a lower risk of AF. The hazard ratios (95% CI) for AF in the top and bottom quartiles were 0.76 (95% CI: 0.61, 0.95) for 18:0; 0.78 (95% CI: 0.63, 0.97) for 20:0; 0.62 (95% CI: 0.50, 0.78) for 22:0; and 0.68 (95% CI: 0.55, 0.85) for 24:0.
Conclusions
Results from this prospective cohort study of older adults demonstrate divergent associations of circulating 16:0 versus longer‐chain saturated fatty acids with incident AF, highlighting the need to investigate both determinants of these levels and potential pathways of the observed differential risk.
doi:10.1161/JAHA.114.000889
PMCID: PMC4309088  PMID: 24970268
atrial fibrillation; epidemiology; fatty acid
8.  Genome-Wide Association Study Identifies Novel Loci Associated With Concentrations of Four Plasma Phospholipid Fatty Acids in the De Novo Lipogenesis Pathway: Results from the CHARGE Consortium 
Background
Palmitic acid(16:0), stearic acid(18:0), palmitoleic acid(16:1n-7), and oleic acid(18:1n-9) are major saturated and mono-unsaturated fatty acids that affect cellular signaling and metabolic pathways. They are synthesized via de novo lipogenesis (DNL) and are the main saturated and mono-unsaturated fatty acids in the diet. Levels of these fatty acids have been linked to diseases including type 2 diabetes and coronary heart disease.
Methods and Results
Genome-wide association studies were conducted in 5 population-based cohorts comprising 8,961 participants of European ancestry to investigate the association of common genetic variation with plasma levels of these four fatty acids. We identified polymorphisms in 7 novel loci associated with circulating levels of one or more of these fatty acids. ALG14 (asparagine-linked glycosylation 14 homolog) polymorphisms were associated with higher 16:0(P=2.7×10-11) and lower 18:0(P=2.2×10-18). FADS1 and FADS2 (desaturases) polymorphisms were associated with higher 16:1n-7(P=6.6×10-13) and 18:1n-9(P=2.2×10-32), and lower 18:0(P =1.3×10-20). LPGAT1 (lysophosphatidylglycerol acyltransferase) polymorphisms were associated with lower 18:0(P=2.8×10-9). GCKR(glucokinase regulator, P =9.8×10-10) and HIF1AN(factor inhibiting hypoxia-inducible factor-1, P=5.7×10-9) polymorphisms were associated with higher 16:1n-7, whereas PKD2L1(polycystic kidney disease 2-like 1, P=5.7×10-15) and a locus on chromosome 2(not near known genes) were associated with lower 16:1n-7(P=4.1×10-8).
Conclusion
Our findings provide novel evidence that common variations in genes with diverse functions, including protein-glycosylation, polyunsaturated fatty acid metabolism, phospholipid modeling, and glucose- and oxygen-sensing pathways, are associated with circulating levels of four fatty acids in the DNL pathway. These results expand our knowledge of genetic factors relevant to DNL and fatty acid biology.
doi:10.1161/CIRCGENETICS.112.964619
PMCID: PMC3891054  PMID: 23362303
epidemiology; fatty acids; genome-wide association study
9.  Trans-fatty acid consumption and heart rate variability in two separate cohorts of older and younger adults 
Background
Trans-fatty acid (TFA) consumption is associated with risk of coronary heart disease, and trans-18:2, but not trans-18:1, in red blood cells membranes has been associated with sudden cardiac arrest. Abnormal heart rate variability (HRV) reflects autonomic dysfunction and predicts cardiac death. Relationships between TFA consumption and HRV remain under-studied. We determined whether total TFA consumption, as well as trans-18:1 and trans-18:2 TFA consumption, were independently associated with HRV in two independent cohorts in the US and Portugal.
Methods and Results
In two independent cohorts of older US adults (Cardiovascular Health Study ([CHS], age=72±5yrs, 1989/1995) and young Portuguese adults (Porto, age=19±2yrs, 2008/2010), we assessed habitual TFA intake by food frequency questionnaires in CHS (separately estimating trans-18:1 and trans-18:2) and multiple 24-hour recalls in Porto (estimating total TFA only, which in a subset correlated with circulating trans-18:2, but not trans-18:1, suggesting that we captured the former). HRV was assessed using 24-hour Holters in CHS (N=1,076) and repeated short-term (5-min) ECGs in Porto (N=160). We used multivariate-adjusted linear regression to relate TFA consumption to HRV cross-sectionally (CHS, Porto) and longitudinally (CHS). In CHS, higher trans-18:2 consumption was associated with lower 24-hour standard-deviation-of-all-normal-to-normal-intervals (SDNN) both cross-sectionally (−12%, 95%CI=6–19%, p=0.001) and longitudinally (−15%, 95%CI=4–25 %, p= 0.009), and lower 24-hour SDANN and SDNN-index (p<0.05 each). Higher trans-18:1 consumption in CHS was associated with more favorable 24-hour HRV, in particular time-domain indices (SDNN, SDANN, SDNN-index; p<0.05 each). In Porto, each higher SD TFA consumption was associated with 4% lower 5-min SDNN (95%CI=1–8%, p=0.04), and 7% lower 5-min rMSSD (95%CI=1–13%, p=0.04).
Conclusions
Trans-18:2 consumption is associated with specific, less favorable indices of HRV in both older and young adults. Trans-18:1 consumption is associated with more favorable HRV indices in older adults. Our results support the need to investigate potential HRV related mechanisms whereby trans-18:2 may increase arrhythmic risk.
doi:10.1161/CIRCEP.111.966259
PMCID: PMC3967844  PMID: 22772898
Electrophysiology; trans-fatty acids; heart rate variability; nutrition
10.  Meta-Analysis Investigating Associations Between Healthy Diet and Fasting Glucose and Insulin Levels and Modification by Loci Associated With Glucose Homeostasis in Data From 15 Cohorts 
American Journal of Epidemiology  2012;177(2):103-115.
Whether loci that influence fasting glucose (FG) and fasting insulin (FI) levels, as identified by genome-wide association studies, modify associations of diet with FG or FI is unknown. We utilized data from 15 US and European cohort studies comprising 51,289 persons without diabetes to test whether genotype and diet interact to influence FG or FI concentration. We constructed a diet score using study-specific quartile rankings for intakes of whole grains, fish, fruits, vegetables, and nuts/seeds (favorable) and red/processed meats, sweets, sugared beverages, and fried potatoes (unfavorable). We used linear regression within studies, followed by inverse-variance-weighted meta-analysis, to quantify 1) associations of diet score with FG and FI levels and 2) interactions of diet score with 16 FG-associated loci and 2 FI-associated loci. Diet score (per unit increase) was inversely associated with FG (β = −0.004 mmol/L, 95% confidence interval: −0.005, −0.003) and FI (β = −0.008 ln-pmol/L, 95% confidence interval: −0.009, −0.007) levels after adjustment for demographic factors, lifestyle, and body mass index. Genotype variation at the studied loci did not modify these associations. Healthier diets were associated with lower FG and FI concentrations regardless of genotype at previously replicated FG- and FI-associated loci. Studies focusing on genomic regions that do not yield highly statistically significant associations from main-effect genome-wide association studies may be more fruitful in identifying diet-gene interactions.
doi:10.1093/aje/kws297
PMCID: PMC3707424  PMID: 23255780
diabetes; dietary pattern; gene-environment interaction; glucose; insulin
11.  Plasma Fatty Acid Binding Protein 4 and Risk of Sudden Cardiac Death in Older Adults 
Although fatty acid binding protein 4 (FABP4) may increase risk of diabetes and exert negative cardiac inotropy, it is unknown whether plasma concentrations of FABP4 are associated with incidence of sudden cardiac death (SCD). We prospectively analyzed data on 4,560 participants of the Cardiovascular Health Study. FABP4 was measured at baseline using ELISA, and SCD events were adjudicated through review of medical records. We used Cox proportional hazards to estimate effect measures. During a median followup of 11.8 years, 146 SCD cases occurred. In a multivariable model adjusting for demographic, lifestyle, and metabolic factors, relative risk of SCD associated with each higher standard deviation (SD) of plasma FABP4 was 1.15 (95% CI: 0.95–1.38), P = 0.15. In a secondary analysis stratified by prevalent diabetes status, FABP4 was associated with higher risk of SCD in nondiabetic participants, (RR per SD higher FABP4: 1.33 (95% CI: 1.07–1.65), P = 0.009) but not in diabetic participants (RR per SD higher FABP4: 0.88 (95% CI: 0.62–1.27), P = 0.50), P for diabetes-FABP4 interaction 0.049. In summary, a single measure of plasma FABP4 obtained later in life was not associated with the risk of SCD in older adults overall. Confirmation of our post-hoc results in nondiabetic people in other studies is warranted.
doi:10.1155/2013/181054
PMCID: PMC3888692  PMID: 24455402
12.  Circulating Omega‐3 Polyunsaturated Fatty Acids and Subclinical Brain Abnormalities on MRI in Older Adults: The Cardiovascular Health Study 
Background
Consumption of tuna or other broiled or baked fish, but not fried fish, is associated with fewer subclinical brain abnormalities on magnetic resonance imaging (MRI). We investigated the association between plasma phospholipid omega‐3 polyunsaturated fatty acids (PUFAs), objective biomarkers of exposure, and subclinical brain abnormalities on MRI.
Methods and Results
In the community‐based Cardiovascular Health Study, 3660 participants aged ≥65 underwent brain MRI in 1992–1994, and 2313 were rescanned 5 years later. MRIs were centrally read by neuroradiologists in a standardized, blinded manner. Participants with recognized transient ischemic attacks or stroke were excluded. Phospholipid PUFAs were measured in stored plasma collected in 1992–1993 and related to cross‐sectional and longitudinal MRI findings. After multivariable adjustment, the odds ratio for having a prevalent subclinical infarct was 0.60 (95% CI, 0.44 to 0.82; P for trend=0.001) in the highest versus lowest long‐chain omega‐3 PUFA quartile. Higher long‐chain omega‐3 PUFA content was also associated with better white matter grade, but not with sulcal or ventricular grades, markers of brain atrophy, or with incident subclinical infarcts. The phospholipid intermediate‐chain omega‐3 PUFA alpha‐linolenic acid was associated only with modestly better sulcal and ventricular grades. However, this finding was not supported in the analyses with alpha‐linolenic acid intake.
Conclusions
Among older adults, higher phospholipid long‐chain omega‐3 PUFA content was associated with lower prevalence of subclinical infarcts and better white matter grade on MRI. Our results support the beneficial effects of fish consumption, the major source of long‐chain omega‐3 PUFAs, on brain health in later life. The role of plant‐derived alpha‐linolenic acid in brain health requires further investigation.
doi:10.1161/JAHA.113.000305
PMCID: PMC3835236  PMID: 24113325
fatty acids; fish; magnetic resonance imaging; lacunar infarct; white matter disease
13.  Common Variation in Fatty Acid Genes and Resuscitation from Sudden Cardiac Arrest 
Background
Fatty acids provide energy and structural substrates for the heart and brain and may influence resuscitation from sudden cardiac arrest (SCA). We investigated whether genetic variation in fatty acid metabolism pathways was associated with SCA survival.
Methods and Results
Subjects (mean age 67, 80% male, Caucasian) were out-of-hospital SCA patients found in ventricular fibrillation in King County, WA. We compared subjects who survived to hospital admission (n=664) with those who did not (n=689), and subjects who survived to hospital discharge (n=334) with those who did not (n=1019). Associations between survival and genetic variants were assessed using logistic regression adjusting for age, gender, location, time to arrival of paramedics, whether the event was witnessed, and receipt of bystander CPR. Within-gene permutation tests were used to correct for multiple comparisons. Variants in five genes were significantly associated with SCA survival. After correction for multiple comparisons, SNPs in ACSL1 and ACSL3 were significantly associated with survival to hospital admission. SNPs in ACSL3, AGPAT3, MLYCD, and SLC27A6 were significantly associated with survival to hospital discharge.
Conclusions
Our findings indicate that variants in genes important in fatty acid metabolism are associated with SCA survival in this population.
doi:10.1161/CIRCGENETICS.111.961912
PMCID: PMC3422654  PMID: 22661490
epidemiology; fatty acids; genetics; heart arrest
14.  Biomarkers of Dairy Fatty Acids and Risk of Cardiovascular Disease in the Multi‐Ethnic Study of Atherosclerosis 
Background
Evidence regarding the role of dairy fat intake in cardiovascular disease (CVD) has been mixed and inconclusive. Most earlier studies have used self‐reported measures of dietary intake and focused on relatively racially homogeneous populations. Circulating biomarkers of dairy fat in a multiethnic cohort provide objective measures of dairy fat intake and facilitate conclusions relevant to populations with different diets and susceptibility to CVD.
Methods and Results
In a multiethnic cohort of 2837 US adults aged 45 to 84 years at baseline (2000–2002), phospholipid fatty acids including 15:0, 14:0, and trans‐16:1n7 were measured using standardized methods, and the incidence of CVD prospectively adjudicated. Self‐reported whole‐fat dairy and butter intakes had strongest associations with 15:0, rather than 14:0 or trans‐16:1n7. In multivariate models including demographics and lifestyle and dietary habits, each SD‐unit of 15:0 was associated with 19% lower CVD risk (hazard ratio [95% CI] 0.81 [0.68 to 0.98]) and 26% lower coronary heart disease (CHD) risk (0.74 [0.60 to 0.92]). Associations were strengthened after mutual adjustment for 14:0 and trans‐16:1n‐7 and were similar after adjustment for potential mediators. Plasma phospholipid 14:0 and trans‐16:1n‐7 were not significantly associated with incident CVD or CHD. All findings were similar in white, black, Hispanic, and Chinese American participants.
Conclusion
Plasma phospholipid 15:0, a biomarker of dairy fat, was inversely associated with incident CVD and CHD, while no association was found with phospholipid 14:0 and trans‐16:1n‐7. These findings support the need for further investigation of CVD effects of dairy fat, dairy‐specific fatty acids, and dairy products in general.
doi:10.1161/JAHA.113.000092
PMCID: PMC3828802  PMID: 23868191
cardiovascular diseases; dairy fat; diet; fatty acids
15.  Long-chain monounsaturated fatty acids and incidence of congestive heart failure in two prospective cohorts 
Circulation  2013;127(14):1512-152218.
Background
Decades-old animal experiments suggested dietary long-chain monounsaturated fatty acids (LCMUFA) caused cardiotoxicity, leading, for example, Canada to develop Canadian-oil-low-in-erucic-acid (Canola) from rapeseed. However, potential cardiotoxicity in humans and contemporary dietary sources of LCMUFA are unknown.
Methods and Results
We prospectively investigated associations of plasma phospholipid LCMUFA (20:1, 22:1, and 24:1), objective biomarkers of exposure, with incidence congestive heart failure (CHF) in two independent cohorts: 3,694 older adults (mean age=75.2±5.2 years) in the Cardiovascular Health Study (CHS, 1992–2006), and 3,577 middle-aged adults (mean age=54.1±5.8 years) in the Atherosclerosis Risk in Communities Study Minnesota subcohort (ARIC, 1987–2008). We further examined dietary correlates of circulating LCMUFA in CHS and ARIC, and US dietary sources of LCMUFA in the 2003–2010 National Health and Nutrition Examination Survey (NHANES). In CHS, 997 CHF events occurred during 39,238 person-years; and in ARIC, 330 events during 64,438 person-years. After multivariable-adjustment, higher levels of 22:1 and 24:1 were positively associated with greater incident CHF in both CHS and ARIC: hazard ratios (95% confidence interval)=1.34 (1.02–1.76) and 1.57 (1.11–2.23) for highest vs. lowest quintiles of 22:1, respectively; and 1.75 (1.23–2.50) and 1.92 (1.22–3.03) for 24:1, respectively (P-trend≤0.03 each). A variety of foods related to circulating LCMUFA in CHS and ARIC, consistent with food sources of LCMUFA in NHANES, including fish, poultry, meats, whole grains, and mustard.
Conclusions
Higher circulating levels of 22:1 and 24:1, with apparently diverse dietary sources, were associated with incident CHF in two independent cohorts, suggesting possible cardiotoxicity of LCMUFA in humans.
doi:10.1161/CIRCULATIONAHA.112.001197
PMCID: PMC3717970  PMID: 23487436
congestive heart failure; fatty acids; diet; epidemiology
16.  Plasma Phospholipid Long-Chain Omega-3 Fatty Acids and Total and Cause-Specific Mortality in Older Adults: the Cardiovascular Health Study 
Annals of internal medicine  2013;158(7):515-525.
Background
Long-chain n-3 polyunsaturated fatty acids (n3-PUFA), including eicosapentaenoic acid (EPA/20:5n-3), docosapentaenoic acid (DPA/22:5n-3), and docosahexaenoic acid (DHA/22:6n-3), experimentally reduce cardiovascular risk. Yet, effects on cause-specific and total mortality and potential dose-responses remain controversial. Most observational studies have assessed self-reported dietary intakes, rather than objective biomarkers; while most randomized trials have tested effects of adding supplements to background dietary intake and evaluated secondary prevention, limiting inference for dietary n3-PUFA or primary prevention.
Objective
We investigated associations of plasma phospholipid EPA, DPA, DHA, and total n-3 PUFA with total and cause-specific mortality among generally healthy older adults not taking fish oil supplements.
Design
Prospective cohort, 1992–2008.
Setting
Four U.S. communities.
Participants
2,692 U.S. adults age 75±5 years, free of prevalent coronary heart disease (CHD), stroke, or heart failure.
Measurements
Phospholipid fatty acids and cardiovascular risk factors were measured in 1992 using standardized methods. Relationships with total and cause-specific mortality through 2008, and incident total (fatal+nonfatal) CHD and stroke, were assessed using Cox proportional-hazards.
Results
During 30,829 person-years, 1,625 deaths (including 570 cardiovascular deaths), 359 fatal and 371 nonfatal CHD events, and 130 fatal and 276 nonfatal strokes occurred. After multivariable-adjustment, n3-PUFA biomarkers associated with lower total mortality, with extreme-quintile hazard ratios (95% CI) of 0.83 for EPA (0.71–0.98), 0.77 for DPA (0.66–0.90), 0.80 for DHA (0.67–0.94), and 0.73 for total n3-PUFA (0.61–0.86) (P-trend≤0.008 each). Lower risk was largely attributable to fewer cardiovascular, rather than noncardiovascular, deaths, in particular fewer arrhythmic cardiac deaths (total n3-PUFA: hazard ratio=0.52, 95%CI=0.31–0.86; P-trend=0.008). Based on relations with total mortality, individuals in the highest quintile of phospholipid n3-PUFA, versus the lowest, experienced 2.22 greater years of life (95%CI=0.75–3.13) after age 65.
Limitations
Temporal changes in fatty acid levels and misclassification of death causes may cause underestimated associations; and unmeasured/imperfectly measured covariates, residual confounding.
Conclusions
Circulating individual and total n3-PUFA are associated with lower total mortality, especially CHD death, in older adults.
Primary Funding Source
National Institutes of Health.
doi:10.7326/0003-4819-158-7-201304020-00003
PMCID: PMC3698844  PMID: 23546563
17.  Major Life Events as Potential Triggers of Sudden Cardiac Arrest 
Epidemiology (Cambridge, Mass.)  2012;23(3):482-485.
Background
We investigated recent loss of or separation from afamily member or friend and risk of sudden cardiac arrest.
Methods
Our case-crossover study included 490 apparently-healthy married residents of King County, Washington, who suffered sudden cardiac arrest between 1988 and 2005. We compared exposure to spouse-reported family/friend events occurring ≤ 1 month before sudden cardiac arrest with events occurring n the previous 5 months. We evaluated potential effect modification by habitual vigorous physical activity.
Results
Recent family/friend events were associated with a higher risk of sudden cardiac arrest (odds ratio (OR) = 1.6 [95% confidence interval (CI) = 1.1-2.4]). ORs for cases with and without habitual vigorous physical activity were 1.1 (0.6-2.2) and 2.0 (1.2-3.1), respectively, (interaction P = 0.02).
Conclusions
These results suggest family/friend events may trigger sudden cardiac arrest and raise the hypothesis that habitual vigorous physical activity may lower susceptibility to these potential triggers.
doi:10.1097/EDE.0b013e31824d5d82
PMCID: PMC3443411  PMID: 22415111
18.  Non-esterified Fatty Acids and Risk of Sudden Cardiac Death in Older Adults 
Background
While non-esterified fatty acids (NEFA) have been positively associated with coronary heart disease risk factors, limited and inconsistent data are available on the relation between NEFA and sudden cardiac death.
Methods and Results
Using a prospective design, we studied 4,657 older men and women (mean age 75 y) from the Cardiovascular Health Study (1992-2006) to evaluate the association between plasma NEFA and the risk of sudden cardiac death in older adults. Plasma concentrations of NEFA were measured using established enzymatic methods and sudden death was adjudicated using medical records, death certificates, proxy interview, and autopsy reports. We used Cox proportional hazard models to estimate multivariable-adjusted relative risks. During a median follow-up of 10.0 years, 221 new cases of sudden cardiac death occurred. In a multivariable model adjusting for age, sex, race, clinic site, alcohol intake, smoking, prevalent coronary heart disease and heart failure, and self-reported health status, relative risks (95% CI) for sudden cardiac death were 1.0 (ref), 1.15 (0.81-1.64), 1.06 (0.72-1.55), and 0.91 (0.60-1.38) across consecutive quartiles of NEFA concentration. In secondary analyses restricted to the first five years of follow up, we also did not observe a statistically significant association between plasma NEFA and sudden cardiac death.
Conclusions
Our data do not provide evidence for an association between plasma NEFA measured late in life and the risk of sudden cardiac death in older adults.
doi:10.1161/CIRCEP.111.967661
PMCID: PMC3329563  PMID: 22281952
epidemiology; sudden death; fatty acid binding protein 4; risk factors
19.  Association of Plasma Phospholipid Long-Chain Omega-3 Fatty Acids with Incident Atrial Fibrillation in Older Adults: The Cardiovascular Health Study 
Circulation  2012;125(9):1084-1093.
Background
Experimental studies suggest long-chain n-3 polyunsaturated fatty acids (n-3 PUFA) may reduce risk of atrial fibrillation (AF). Prior studies evaluating fish or n-3 PUFA consumption from dietary questionnaires and incident AF have been conflicting. Circulating levels of n-3 PUFA provide an objective measurement of exposure.
Methods and Results
Among 3,326 US men and women age≥65y and free of AF or heart failure at baseline, plasma phospholipid levels of eicosapentaenoic acid (EPA), docosapentaenoic acid (DPA), and docosahexaenoic acid (DHA) were measured at baseline using standardized methods. Incident AF (789 cases) was prospectively identified from hospital discharge records and study visit electrocardiograms during 31,169 person-years of follow-up (1992-2006). In multivariable Cox models adjusted for other risk factors, the RR in the top versus lowest quartile of total n-3 PUFA (EPA+DPA+DHA) levels was 0.71 (95%CI=0.57-0.89, P-trend=0.004); and of DHA levels, 0.77 (95%CI=0.62-0.96, P-trend=0.01). EPA and DPA levels were not significantly associated with incident AF. Evaluated non-parametrically, both total n-3 PUFA and DHA showed graded and linear inverse associations with incidence of AF. Adjustment for intervening events such as heart failure or myocardial infarction during follow-up did not appreciably alter results.
Conclusions
In older adults, higher circulating total long-chain n-3 PUFA and DHA levels were associated with lower risk of incident AF. These results highlight the need to evaluate whether increased dietary intake of these fatty acids could be effective for primary prevention of AF.
doi:10.1161/CIRCULATIONAHA.111.062653
PMCID: PMC3302663  PMID: 22282329
atrial fibrillation; biomarkers; epidemiology; fatty acids
20.  Associations of Plasma Phospholipid and Dietary Alpha Linolenic Acid With Incident Atrial Fibrillation in Older Adults: The Cardiovascular Health Study 
Background
Few studies have examined the relationship of α‐linolenic acid (ALA 18:3n‐3), an intermediate‐chain essential n‐3 polyunsaturated fatty acid derived from plants and vegetable oils, with incident atrial fibrillation (AF).
Methods and Results
The study population included participants from the Cardiovascular Health Study, a community‐based longitudinal cohort of adults aged 65 or older, free of prevalent coronary heart disease and atrial fibrillation. We assessed the associations of plasma phospholipid and dietary ALA with incident AF using Cox regression. The biomarker analysis comprised a total of 2899 participants, and the dietary analysis comprised 4337 participants. We found no association of plasma phospholipid ALA and incident AF. Comparing each of the second, third, and fourth quartiles to the lowest quartile, the hazard ratios for AF were 1.11 (95% CI, 0.90 to 1.37), 1.09 (95% CI, 0.88 to 1.35), and 0.92 (95% CI, 0.74 to 1.15), after adjustment for age, sex, race, clinic, education, smoking, alcohol, body mass index, waist circumference, diabetes, heart failure, stroke, treated hypertension, and physical activity (P trend=0.48). When dietary ALA was considered the exposure of interest, results were similar.
Conclusions
Results from this prospective cohort study of older adults indicate no association of plasma phospholipid or dietary ALA and incident AF.
doi:10.1161/JAHA.112.003814
PMCID: PMC3603242  PMID: 23525429
atrial fibrillation; epidemiology; fatty acids; nutrition
21.  Total Zinc Intake May Modify the Glucose-Raising Effect of a Zinc Transporter (SLC30A8) Variant 
Diabetes  2011;60(9):2407-2416.
OBJECTIVE
Many genetic variants have been associated with glucose homeostasis and type 2 diabetes in genome-wide association studies. Zinc is an essential micronutrient that is important for β-cell function and glucose homeostasis. We tested the hypothesis that zinc intake could influence the glucose-raising effect of specific variants.
RESEARCH DESIGN AND METHODS
We conducted a 14-cohort meta-analysis to assess the interaction of 20 genetic variants known to be related to glycemic traits and zinc metabolism with dietary zinc intake (food sources) and a 5-cohort meta-analysis to assess the interaction with total zinc intake (food sources and supplements) on fasting glucose levels among individuals of European ancestry without diabetes.
RESULTS
We observed a significant association of total zinc intake with lower fasting glucose levels (β-coefficient ± SE per 1 mg/day of zinc intake: −0.0012 ± 0.0003 mmol/L, summary P value = 0.0003), while the association of dietary zinc intake was not significant. We identified a nominally significant interaction between total zinc intake and the SLC30A8 rs11558471 variant on fasting glucose levels (β-coefficient ± SE per A allele for 1 mg/day of greater total zinc intake: −0.0017 ± 0.0006 mmol/L, summary interaction P value = 0.005); this result suggests a stronger inverse association between total zinc intake and fasting glucose in individuals carrying the glucose-raising A allele compared with individuals who do not carry it. None of the other interaction tests were statistically significant.
CONCLUSIONS
Our results suggest that higher total zinc intake may attenuate the glucose-raising effect of the rs11558471 SLC30A8 (zinc transporter) variant. Our findings also support evidence for the association of higher total zinc intake with lower fasting glucose levels.
doi:10.2337/db11-0176
PMCID: PMC3161318  PMID: 21810599
22.  Type 2 diabetes mellitus and the risk of sudden cardiac arrest in the community 
The reduction of mortality from sudden cardiac arrest (SCA) in the setting of coronary heart disease (CHD) remains a major challenge, especially among patients with type 2 diabetes. Diabetes is associated with an increased risk of SCA, at least in part, from an increased presence and extent of coronary atherosclerosis (macrovascular disease). Diabetes also is associated with microvascular disease and autonomic neuropathy; and, these non-coronary atherosclerotic pathophysiologic processes also have the potential to increase the risk of SCA. In this report, we review the absolute and relative risk of SCA associated with diabetes. We summarize recent evidence that suggests that the increase in risk in patients with diabetes is not specific for SCA, as diabetes also is associated with a similar increase in risk for non-SCA CHD death and non-fatal myocardial infarction. These data are consistent with prior observations that coronary atherosclerosis is a major contributor to the increased SCA risk associated with diabetes. We also present previously published and unpublished data that demonstrates that both clinically-recognized microvascular and autonomic neuropathy also are associated with the risk of SCA among treated patients with diabetes, after taking into account prior clinically-recognized heart disease and other risk factors for SCA. We then discuss how these data might inform research and clinical efforts to prevent SCA. Although the prediction of SCA in this “high” risk population is likely to remain a challenge, as it is in other “high” risk clinical populations, we suggest that current recommendations for the prevention of SCA in the community, related to both lifestyle prescriptions and risk factor reduction, are likely to reduce mortality from SCA among patients with diabetes.
doi:10.1007/s11154-010-9133-5
PMCID: PMC3413310  PMID: 20195771
Diabetes mellitus; Sudden cardiac death; Cardiac arrest; Coronary heart disease; Autonomic dysfunction; Microvascular disease
23.  Circulating Long-Chain Omega-3 Fatty Acids and Incidence of Congestive Heart Failure in Older Adults: the Cardiovascular Health Study 
Annals of Internal Medicine  2011;155(3):160-170.
Background
Few prior studies have evaluated long-chain omega-3 fatty acids and incidence of congestive heart failure (CHF), typically based on diet questionnaires and with conflicting results. Circulating fatty acid levels provide objective biomarkers of exposure.
Objective
We investigated whether plasma phospholipid levels of long-chain omega-3 fatty acids, including eicosapentaenoic acid (EPA, 20:5n-3), docosapentaenoic acid (DPA, 22:5n-3), and docosahexaenoic acid (DHA, 22:6n-3) were associated with incident CHF.
Design
Prospective cohort study, 1992–2006.
Setting
Four U.S. communities.
Patients
2,735 U.S. adults free of prevalent heart disease in the Cardiovascular Health Study.
Measurements
Plasma phospholipid fatty acids and other cardiovascular risk factors were measured in 1992 using standardized methods. Relationships with incident CHF (555 cases during 26,490 person-years, adjudicated using medical records) were assessed using Cox proportional-hazards.
Results
After multivariable-adjustment, plasma phospholipid EPA was inversely associated with incident CHF, with approximately 50% lower risk in the highest vs. lowest quartile [hazard ratio (95%CI)=0.52 (0.38–0.72), P-trend=0.001]. In similar analyses, trends toward lower risk were seen for DPA [0.76 (0.56–1.04), P-trend=0.057] and total long-chain n-3 fatty acids [0.70 (0.49–0.99); P-trend= 0.062], but not DHA [0.84 (0.58–1.21); P-trend=0.38]. In analyses censored to mid-follow-up (7 years) to minimize exposure misclassification over time, multivariable-adjusted hazard ratios (95%CI) were 0.48 for EPA (0.32–0.71; P-trend=0.005); 0.61 for DPA (0.39–0.95; P-trend=0.033); 0.64 for DHA (0.40–1.04; P-trend=0.057); and 0.51 for total n-3 fatty acids (0.32–0.80; P-trend=0.003).
Limitations
Temporal changes in fatty acid levels over time may have caused underestimation of associations. Unmeasured or imperfectly measured covariates may have caused residual confounding.
Conclusions
Circulating individual and total n-3 fatty acids are associated with lower incidence of CHF in older adults.
Primary Funding Source
National Institutes of Health.
doi:10.1059/0003-4819-155-3-201108020-00006
PMCID: PMC3371768  PMID: 21810709
24.  Trans-Palmitoleic Acid, Metabolic Risk Factors, and New-Onset Diabetes in US Adults 
Annals of internal medicine  2010;153(12):790-799.
Background
Palmitoleic acid (cis-16:1n-7), produced by endogenous fat synthesis, has been linked to both beneficial and deleterious metabolic effects, potentially confounded by diverse determinants and tissue sources of endogenous production. Trans-palmitoleate (trans-16:1n-7) represents a distinctly exogenous source of 16:1n-7, unconfounded by endogenous synthesis or its determinants, that may be uniquely informative.
Objective
We investigated whether circulating trans-palmitoleate was independently related to lower metabolic risk and incident type2 diabetes.
Design
Prospective cohort study (1992–2006).
Setting
Four US communities.
Patients
3,736 adults in the Cardiovascular Health Study.
Measurements
Plasma phospholipid fatty acids, anthropometry, blood lipids, inflammatory markers, and glucose-insulin levels were measured at baseline in 1992; and diet, 3 years earlier. In multivariable-adjusted models, we investigated how demographic, clinical, and lifestyle factors independently related to trans-palmitoleate; how trans-palmitoleate related to major metabolic risk factors; and how trans-palmitoleate related to new-onset diabetes (304 incident cases). We validated findings for metabolic risk factors in an independent cohort of 327 women.
Results
In multivariable-analyses, whole-fat dairy consumption was most strongly associated with higher trans-palmitoleate. Higher trans-palmitoleate was associated with slightly lower adiposity and, independently, higher high-density-lipoprotein(HDL)-cholesterol (across quintiles: +1.9%, P=0.04), lower triglycerides (−19.0%, P<0.001), lower total:HDL-cholesterol (−4.7%, P<0.001), lower C-reactive protein (−13.8%, P=0.05), and lower insulin resistance (−16.7%, P<0.001). Trans-palmitoleate was associated with substantially lower incidence of diabetes, with multivariable-hazard-ratios=0.41 (95%CI=0.27–0.64) and 0.38 (95%CI=0.24–0.62) in quintile-4 and quintile-5, versus quintile-1 (P-trend<0.001). Findings were independent of estimated dairy consumption or other fatty acid dairy biomarkers. Protective associations with metabolic risk factors were confirmed in the validation cohort.
Limitations
Measurement error; residual confounding.
Conclusions
Circulating trans-palmitoleate is associated with lower insulin resistance, atherogenic dyslipidemia, and incident diabetes. Our findings may explain previously observed metabolic benefits of dairy consumption and support need for detailed further experimental and clinical investigation.
Primary Funding Source
National Institutes of Health.
doi:10.1059/0003-4819-153-12-201012210-00005
PMCID: PMC3056495  PMID: 21173413
25.  Interactions of Dietary Whole-Grain Intake With Fasting Glucose– and Insulin-Related Genetic Loci in Individuals of European Descent 
Diabetes Care  2010;33(12):2684-2691.
OBJECTIVE
Whole-grain foods are touted for multiple health benefits, including enhancing insulin sensitivity and reducing type 2 diabetes risk. Recent genome-wide association studies (GWAS) have identified several single nucleotide polymorphisms (SNPs) associated with fasting glucose and insulin concentrations in individuals free of diabetes. We tested the hypothesis that whole-grain food intake and genetic variation interact to influence concentrations of fasting glucose and insulin.
RESEARCH DESIGN AND METHODS
Via meta-analysis of data from 14 cohorts comprising ∼48,000 participants of European descent, we studied interactions of whole-grain intake with loci previously associated in GWAS with fasting glucose (16 loci) and/or insulin (2 loci) concentrations. For tests of interaction, we considered a P value <0.0028 (0.05 of 18 tests) as statistically significant.
RESULTS
Greater whole-grain food intake was associated with lower fasting glucose and insulin concentrations independent of demographics, other dietary and lifestyle factors, and BMI (β [95% CI] per 1-serving-greater whole-grain intake: −0.009 mmol/l glucose [−0.013 to −0.005], P < 0.0001 and −0.011 pmol/l [ln] insulin [−0.015 to −0.007], P = 0.0003). No interactions met our multiple testing–adjusted statistical significance threshold. The strongest SNP interaction with whole-grain intake was rs780094 (GCKR) for fasting insulin (P = 0.006), where greater whole-grain intake was associated with a smaller reduction in fasting insulin concentrations in those with the insulin-raising allele.
CONCLUSIONS
Our results support the favorable association of whole-grain intake with fasting glucose and insulin and suggest a potential interaction between variation in GCKR and whole-grain intake in influencing fasting insulin concentrations.
doi:10.2337/dc10-1150
PMCID: PMC2992213  PMID: 20693352

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