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1.  No Association of Coronary Artery Disease with X-Chromosomal Variants in Comprehensive International Meta-Analysis 
Loley, Christina | Alver, Maris | Assimes, Themistocles L. | Bjonnes, Andrew | Goel, Anuj | Gustafsson, Stefan | Hernesniemi, Jussi | Hopewell, Jemma C. | Kanoni, Stavroula | Kleber, Marcus E. | Lau, King Wai | Lu, Yingchang | Lyytikäinen, Leo-Pekka | Nelson, Christopher P. | Nikpay, Majid | Qu, Liming | Salfati, Elias | Scholz, Markus | Tukiainen, Taru | Willenborg, Christina | Won, Hong-Hee | Zeng, Lingyao | Zhang, Weihua | Anand, Sonia S. | Beutner, Frank | Bottinger, Erwin P. | Clarke, Robert | Dedoussis, George | Do, Ron | Esko, Tõnu | Eskola, Markku | Farrall, Martin | Gauguier, Dominique | Giedraitis, Vilmantas | Granger, Christopher B. | Hall, Alistair S. | Hamsten, Anders | Hazen, Stanley L. | Huang, Jie | Kähönen, Mika | Kyriakou, Theodosios | Laaksonen, Reijo | Lind, Lars | Lindgren, Cecilia | Magnusson, Patrik K. E. | Marouli, Eirini | Mihailov, Evelin | Morris, Andrew P. | Nikus, Kjell | Pedersen, Nancy | Rallidis, Loukianos | Salomaa, Veikko | Shah, Svati H. | Stewart, Alexandre F. R. | Thompson, John R. | Zalloua, Pierre A. | Chambers, John C. | Collins, Rory | Ingelsson, Erik | Iribarren, Carlos | Karhunen, Pekka J. | Kooner, Jaspal S. | Lehtimäki, Terho | Loos, Ruth J. F. | März, Winfried | McPherson, Ruth | Metspalu, Andres | Reilly, Muredach P. | Ripatti, Samuli | Sanghera, Dharambir K. | Thiery, Joachim | Watkins, Hugh | Deloukas, Panos | Kathiresan, Sekar | Samani, Nilesh J. | Schunkert, Heribert | Erdmann, Jeanette | König, Inke R.
Scientific Reports  2016;6:35278.
In recent years, genome-wide association studies have identified 58 independent risk loci for coronary artery disease (CAD) on the autosome. However, due to the sex-specific data structure of the X chromosome, it has been excluded from most of these analyses. While females have 2 copies of chromosome X, males have only one. Also, one of the female X chromosomes may be inactivated. Therefore, special test statistics and quality control procedures are required. Thus, little is known about the role of X-chromosomal variants in CAD. To fill this gap, we conducted a comprehensive X-chromosome-wide meta-analysis including more than 43,000 CAD cases and 58,000 controls from 35 international study cohorts. For quality control, sex-specific filters were used to adequately take the special structure of X-chromosomal data into account. For single study analyses, several logistic regression models were calculated allowing for inactivation of one female X-chromosome, adjusting for sex and investigating interactions between sex and genetic variants. Then, meta-analyses including all 35 studies were conducted using random effects models. None of the investigated models revealed genome-wide significant associations for any variant. Although we analyzed the largest-to-date sample, currently available methods were not able to detect any associations of X-chromosomal variants with CAD.
PMCID: PMC5059659  PMID: 27731410
2.  Longitudinal relationships between glycemic status and body mass index in a multiethnic study: evidence from observational and genetic epidemiology 
Scientific Reports  2016;6:30744.
We investigated the relationship between glycemic status and BMI and its interaction with obesity single-nucleotide polymorphisms (SNPs) in a multi-ethnic longitudinal cohort at high-risk for dysglycemia. We studied 17 394 participants from six ethnicities followed-up for 3.3 years. Twenty-three obesity SNPs were genotyped and an unweighted genotype risk score (GRS) was calculated. Glycemic status was defined using an oral glucose tolerance test. Linear regression models were adjusted for age, sex and population stratification. Normal glucose tolerance (NGT) to dysglycemia transition was associated with baseline BMI and BMI change. Impaired fasting glucose/impaired glucose tolerance to type 2 diabetes transition was associated with baseline BMI but not BMI change. No simultaneous significant main genetic effects and interactions between SNPs/GRS and glycemic status or transition on BMI level and BMI change were observed. Our data suggests that the interplay between glycemic status and BMI trajectory may be independent of the effects of obesity genes. This implies that individuals with different glycemic statuses may be combined together in genetic association studies on obesity traits, if appropriate adjustments for glycemic status are performed. Implementation of population-wide weight management programs may be more beneficial towards individuals with NGT than those at a later disease stage.
PMCID: PMC4969745  PMID: 27480816
3.  Rationale, design, and methods for Canadian alliance for healthy hearts and minds cohort study (CAHHM) – a Pan Canadian cohort study 
BMC Public Health  2016;16:650.
The Canadian Alliance for Healthy Hearts and Minds (CAHHM) is a pan-Canadian, prospective, multi-ethnic cohort study being conducted in Canada. The overarching objective of the CAHHM is to understand the association of socio-environmental and contextual factors (such as societal structure, activity, nutrition, social and tobacco environments, and access to health services) with cardiovascular risk factors, subclinical vascular disease, and cardiovascular and other chronic disease outcomes.
Participants between 35 and 69 years of age are being recruited from existing cohorts and a new First Nations Cohort to undergo a detailed assessment of health behaviours (including diet and physical activity), cognitive function, assessment of their local home and workplace environments, and their health services access and utilization. Physical measures including weight, height, waist/hip circumference, body fat percentage, and blood pressure are collected. In addition, eligible participants undergo magnetic resonance imaging (MRI) of the brain, heart, carotid artery and abdomen to detect early subclinical vascular disease and ectopic fat deposition.
CAHHM is a prospective cohort study designed to investigate the impact of community level factors, individual health behaviours, and access to health services, on cognitive function, subclinical vascular disease, fat distribution, and the development of chronic diseases among adults living in Canada.
Electronic supplementary material
The online version of this article (doi:10.1186/s12889-016-3310-8) contains supplementary material, which is available to authorized users.
PMCID: PMC4963999  PMID: 27464510
4.  Contribution of common non-synonymous variants in PCSK1 to body mass index variation and risk of obesity: a systematic review and meta-analysis with evidence from up to 331 175 individuals 
Human Molecular Genetics  2015;24(12):3582-3594.
Polymorphisms rs6232 and rs6234/rs6235 in PCSK1 have been associated with extreme obesity [e.g. body mass index (BMI) ≥ 40 kg/m2], but their contribution to common obesity (BMI ≥ 30 kg/m2) and BMI variation in a multi-ethnic context is unclear. To fill this gap, we collected phenotypic and genetic data in up to 331 175 individuals from diverse ethnic groups. This process involved a systematic review of the literature in PubMed, Web of Science, Embase and the NIH GWAS catalog complemented by data extraction from pre-existing GWAS or custom-arrays in consortia and single studies. We employed recently developed global meta-analytic random-effects methods to calculate summary odds ratios (OR) and 95% confidence intervals (CIs) or beta estimates and standard errors (SE) for the obesity status and BMI analyses, respectively. Significant associations were found with binary obesity status for rs6232 (OR = 1.15, 95% CI 1.06–1.24, P = 6.08 × 10−6) and rs6234/rs6235 (OR = 1.07, 95% CI 1.04–1.10, P = 3.00 × 10−7). Similarly, significant associations were found with continuous BMI for rs6232 (β = 0.03, 95% CI 0.00–0.07; P = 0.047) and rs6234/rs6235 (β = 0.02, 95% CI 0.00–0.03; P = 5.57 × 10−4). Ethnicity, age and study ascertainment significantly modulated the association of PCSK1 polymorphisms with obesity. In summary, we demonstrate evidence that common gene variation in PCSK1 contributes to BMI variation and susceptibility to common obesity in the largest known meta-analysis published to date in genetic epidemiology.
PMCID: PMC4498155  PMID: 25784503
5.  Food Consumption and its impact on Cardiovascular Disease: Importance of Solutions focused on the globalized food system 
Major scholars in the field, based on a 3-day consensus, created an in-depth review of current knowledge on the role of diet in CVD, the changing global food system and global dietary patterns, and potential policy solutions. Evidence from different countries, age/race/ethnicity/socioeconomic groups suggest the health effects studies of foods, macronutrients, and dietary patterns on CVD appear to be far more consistent though regional knowledge gaps are highlighted. There are large gaps in knowledge about the association of macronutrients to CVD in low- and middle-income countries (LMIC), particularly linked with dietary patterns are reviewed. Our understanding of foods and macronutrients in relationship to CVD is broadly clear; however major gaps exist both in dietary pattern research and ways to change diets and food systems. Based on the current evidence, the traditional Mediterranean-type diet, including plant foods/emphasizing plant protein sources, provides a well-tested healthy dietary pattern to reduce CVD.
PMCID: PMC4597475  PMID: 26429085
diet; food consumption; low and middle income countries; food system; cardiovascular disease; climate change
6.  Risk Alleles in/near ADCY5, ADRA2A, CDKAL1, CDKN2A/B, GRB10, and TCF7L2 Elevate Plasma Glucose Levels at Birth and in Early Childhood: Results from the FAMILY Study 
PLoS ONE  2016;11(4):e0152107.
Metabolic abnormalities that lead to type 2 diabetes mellitus begin in early childhood.
We investigate whether common genetic variants identified in adults have an effect on glucose in early life.
610 newborns, 463 mothers, and 366 fathers were included in the present study. Plasma glucose and anthropometric characteristics were collected at birth, 3, and 5 years. After quality assessment, 37 SNPs, which have demonstrated an association with fasting plasma glucose at the genome-wide threshold in adults, were studied. Quantitative trait disequilibrium tests and mixed-effects regressions were conducted to estimate an effect of the SNPs on glucose.
Risk alleles for 6 loci increased glucose levels from birth to 5 years of age (ADCY5, ADRA2A, CDKAL1, CDKN2A/B, GRB10, and TCF7L2, 4.85x10-3 ≤ P ≤ 4.60x10-2). Together, these 6 SNPs increase glucose by 0.05 mmol/L for each risk allele in a genotype score (P = 6.33x10-5). None of the associations described in the present study have been reported previously in early childhood.
Our data support the notion that a subset of loci contributing to plasma glucose variation in adults has an effect at birth and in early life.
PMCID: PMC4822946  PMID: 27049325
7.  A comprehensive 1000 Genomes-based genome-wide association meta-analysis of coronary artery disease 
Nikpay, Majid | Goel, Anuj | Won, Hong-Hee | Hall, Leanne M | Willenborg, Christina | Kanoni, Stavroula | Saleheen, Danish | Kyriakou, Theodosios | Nelson, Christopher P | Hopewell, Jemma C | Webb, Thomas R | Zeng, Lingyao | Dehghan, Abbas | Alver, Maris | Armasu, Sebastian M | Auro, Kirsi | Bjonnes, Andrew | Chasman, Daniel I | Chen, Shufeng | Ford, Ian | Franceschini, Nora | Gieger, Christian | Grace, Christopher | Gustafsson, Stefan | Huang, Jie | Hwang, Shih-Jen | Kim, Yun Kyoung | Kleber, Marcus E | Lau, King Wai | Lu, Xiangfeng | Lu, Yingchang | Lyytikäinen, Leo-Pekka | Mihailov, Evelin | Morrison, Alanna C | Pervjakova, Natalia | Qu, Liming | Rose, Lynda M | Salfati, Elias | Saxena, Richa | Scholz, Markus | Smith, Albert V | Tikkanen, Emmi | Uitterlinden, Andre | Yang, Xueli | Zhang, Weihua | Zhao, Wei | de Andrade, Mariza | de Vries, Paul S | van Zuydam, Natalie R | Anand, Sonia S | Bertram, Lars | Beutner, Frank | Dedoussis, George | Frossard, Philippe | Gauguier, Dominique | Goodall, Alison H | Gottesman, Omri | Haber, Marc | Han, Bok-Ghee | Huang, Jianfeng | Jalilzadeh, Shapour | Kessler, Thorsten | König, Inke R | Lannfelt, Lars | Lieb, Wolfgang | Lind, Lars | Lindgren, Cecilia M | Lokki, Marja-Liisa | Magnusson, Patrik K | Mallick, Nadeem H | Mehra, Narinder | Meitinger, Thomas | Memon, Fazal-ur-Rehman | Morris, Andrew P | Nieminen, Markku S | Pedersen, Nancy L | Peters, Annette | Rallidis, Loukianos S | Rasheed, Asif | Samuel, Maria | Shah, Svati H | Sinisalo, Juha | Stirrups, Kathleen E | Trompet, Stella | Wang, Laiyuan | Zaman, Khan S | Ardissino, Diego | Boerwinkle, Eric | Borecki, Ingrid B | Bottinger, Erwin P | Buring, Julie E | Chambers, John C | Collins, Rory | Cupples, L Adrienne | Danesh, John | Demuth, Ilja | Elosua, Roberto | Epstein, Stephen E | Esko, Tõnu | Feitosa, Mary F | Franco, Oscar H | Franzosi, Maria Grazia | Granger, Christopher B | Gu, Dongfeng | Gudnason, Vilmundur | Hall, Alistair S | Hamsten, Anders | Harris, Tamara B | Hazen, Stanley L | Hengstenberg, Christian | Hofman, Albert | Ingelsson, Erik | Iribarren, Carlos | Jukema, J Wouter | Karhunen, Pekka J | Kim, Bong-Jo | Kooner, Jaspal S | Kullo, Iftikhar J | Lehtimäki, Terho | Loos, Ruth J F | Melander, Olle | Metspalu, Andres | März, Winfried | Palmer, Colin N | Perola, Markus | Quertermous, Thomas | Rader, Daniel J | Ridker, Paul M | Ripatti, Samuli | Roberts, Robert | Salomaa, Veikko | Sanghera, Dharambir K | Schwartz, Stephen M | Seedorf, Udo | Stewart, Alexandre F | Stott, David J | Thiery, Joachim | Zalloua, Pierre A | O’Donnell, Christopher J | Reilly, Muredach P | Assimes, Themistocles L | Thompson, John R | Erdmann, Jeanette | Clarke, Robert | Watkins, Hugh | Kathiresan, Sekar | McPherson, Ruth | Deloukas, Panos | Schunkert, Heribert | Samani, Nilesh J | Farrall, Martin
Nature genetics  2015;47(10):1121-1130.
Existing knowledge of genetic variants affecting risk of coronary artery disease (CAD) is largely based on genome-wide association studies (GWAS) analysis of common SNPs. Leveraging phased haplotypes from the 1000 Genomes Project, we report a GWAS meta-analysis of 185 thousand CAD cases and controls, interrogating 6.7 million common (MAF>0.05) as well as 2.7 million low frequency (0.005
PMCID: PMC4589895  PMID: 26343387
PLoS ONE  2016;11(3):e0150990.
Compared to Caucasians, Chinese achieve a higher blood concentration of statin for a given dose. It remains unknown whether this translates to increased risk of serious statin-associated adverse events amongst Chinese patients.
We conducted a population-based retrospective cohort study of older adults (mean age, 74 years) newly prescribed a statin in Ontario, Canada between 2002 and 2013, where 19,033 Chinese (assessed through a validated surname algorithm) were matched (1:3) by propensity score to 57,099 non-Chinese. This study used linked healthcare databases.
The follow-up observation period (mean 1.1, maximum 10.8 years) was similar between groups, as were the reasons for censoring the observation period (end of follow-up, death, or statin discontinuation). Forty-seven percent (47%) of Chinese were initiated on a higher than recommended statin dose. Compared to non-Chinese, Chinese ethnicity did not associate with any of the four serious statin-associated adverse events assessed in this study [rhabdomyolysis hazard ratio (HR) 0.61 (95% CI 0.28 to 1.34), incident diabetes HR 1.02 (95% CI 0.80 to 1.30), acute kidney injury HR 0.90 (95% CI 0.72 to 1.13), or all-cause mortality HR 0.88 (95% CI 0.74 to 1.05)]. Similar results were observed in subgroups defined by statin type and dose.
We observed no higher risk of serious statin toxicity in Chinese than matched non-Chinese older adults with similar indicators of baseline health. Regulatory agencies should review available data, including findings from our study, to decide if a change in their statin dosing recommendations for people of Chinese ethnicity is warranted.
PMCID: PMC4783028  PMID: 26954681
Scientific Reports  2016;6:18672.
Physical activity (PA) has been shown to reduce the impact of FTO variation and obesity genetic risk scores (GRS) on BMI. We examined this interaction using a quantitative measure of PA and two adiposity indexes in a longitudinal multi-ethnic study. We analyzed the impact of PA on the association between 14 obesity predisposing variants (analyzed independently and as a GRS) and baseline/follow-up obesity measures in the multi-ethnic prospective cohort EpiDREAM (17423 participants from six ethnic groups). PA was analyzed using basic (low-moderate-high) and quantitative measures (metabolic equivalents (METS)), while BMI and the body adiposity index (BAI) were used to measure obesity. Increased PA was associated with decreased BMI/BAI at baseline/follow-up. FTO rs1421085, CDKAL1 rs2206734, TNNl3K rs1514176, GIPR rs11671664 and the GRS were associated with obesity measures at baseline and/or follow-up. Risk alleles of three SNPs displayed nominal associations with increased (NTRK2 rs1211166, BDNF rs1401635) or decreased (NPC1 rs1805081) basic PA score independently of BMI/BAI. Both basic and quantitative PA measures attenuated the association between FTO rs1421085 risk allele and BMI/BAI at baseline and follow-up. Our results show that physical activity can blunt the genetic effect of FTO rs1421085 on adiposity by 36–75% in a longitudinal multi-ethnic cohort.
PMCID: PMC4698633  PMID: 26727462
The Canadian Healthy Infant Longitudinal Development birth cohort was designed to elucidate interactions between environment and genetics underlying development of asthma and allergy. Over 3600 pregnant mothers were recruited from the general population in four provinces with diverse environments. The child is followed to age 5 years, with prospective characterization of diverse exposures during this critical period. Key exposure domains include indoor and outdoor air pollutants, inhalation, ingestion and dermal uptake of chemicals, mold, dampness, biological allergens, pets and pests, housing structure, and living behavior, together with infections, nutrition, psychosocial environment, and medications. Assessments of early life exposures are focused on those linked to inflammatory responses driven by the acquired and innate immune systems. Mothers complete extensive environmental questionnaires including time-activity behavior at recruitment and when the child is 3, 6, 12, 24, 30, 36, 48, and 60 months old. House dust collected during a thorough home assessment at 3–4 months, and biological specimens obtained for multiple exposure-related measurements, are archived for analyses. Geo-locations of homes and daycares and land-use regression for estimating traffic-related air pollution complement time-activity-behavior data to provide comprehensive individual exposure profiles. Several analytical frameworks are proposed to address the many interacting exposure variables and potential issues of co-linearity in this complex data set.
PMCID: PMC4611361  PMID: 25805254
environmental exposure assessment; longitudinal birth cohort; indoor air quality; etiology of asthma; biomarkers; CHILD study
Scientific Reports  2015;5:14521.
South Asians (SA) are at higher risk of cardiometabolic disorders than Europeans (EU), yet the potential determinants of this risk are poorly understood. We tested the hypotheses that 1) South Asians (SA) have greater muscle inflammation compared to Europeans (EU) at similar fat mass 2) differential regional adiposity in SA compared to EU is associated with enhanced muscle inflammation in SA. This cross-sectional study was conducted at a tertiary academic center in Hamilton, Ontario, Canada. The study included 29 EU and 26 SA. Quantitative real-time PCR and western blot were used to measure muscle inflammation. Statistical analysis was done using a General Linear Model. Despite having similar macrophage content to EU, SA muscle had lower levels of chemokine CCL2 compared to EU at gene expression (β -1.099, SE β 0.521, p-value 0.04) and protein (0.84 ± 0.69 versus 1.10 ± 0.60, p-value 0.052) levels. SA had more pronounced abdominal and hepatic adiposity, with smaller Intramyocellular lipid particles compared to EU (0.26 ± 0.12 μm2 versus 0.15 ± 0.06 μm2, p-value 0.02). In conclusion, CCL2 downregulation in SA may be an attempt to protect muscle against macrophage infiltration, and defects in fatty acid partitioning to muscle may lead to the disproportionate adiposity and adverse cardiometabolic profile in SA.
PMCID: PMC4600971  PMID: 26455502
European Heart Journal  2014;35(33):2242-2248.
A genetic variant (rs20417) of the PTGS2 gene, encoding for COX-2, has been associated with decreased COX-2 activity and a decreased risk of cardiovascular disease (CVD). However, this genetic association and the role of COX-2 in CVD remain controversial.
Methods and results
The association of rs20417 with CVD was prospectively explored in 49 232 subjects (ACTIVE-A, CURE, epiDREAM/DREAM, ONTARGET, RE-LY, and WGHS) and the effect of potentially modifiable risk factors on the genetic association was further explored in 9363 INTERHEART participants. The effect of rs20417 on urinary thromboxane and prostacyclin metabolite concentrations was measured in 117 healthy individuals. Carriage of the rs20417 minor allele was associated with a decreased risk of major CVD outcomes (OR = 0.78, 95% CI: 0.70–0.87; P = 1.2 × 10−5). The genetic effect was significantly stronger in aspirin users (OR: 0.74, 95% CI: 0.64−0.84; P = 1.20 × 10−5) than non-users (OR: 0.87, 95% CI: 0.72−1.06; P = 0.16) (interaction P-value: 0.0041). Among patients with previous coronary artery disease (CAD), rs20417 carriers had a stronger protective effect on risk of major adverse events when compared with individuals without previous CAD (interaction P-value: 0.015). Carriers had significantly lower urinary levels of thromboxane (P = 0.01) and prostacyclin (P = 0.01) metabolites when compared with non-carriers.
The rs20417 polymorphism is associated with a reduced risk of major cardiovascular events and lower levels of thromboxane and prostacyclin. Our results suggest that a genetic decrease in COX-2 activity may be beneficial with respect to CVD risk, especially, in higher risk patients on aspirin.
PMCID: PMC4432461  PMID: 24796340
Pharmacogenetics; Genetics; Aspirin; Myocardial infarction; Stroke
The BMJ  2015;351:h3978.
Objective To systematically review associations between intake of saturated fat and trans unsaturated fat and all cause mortality, cardiovascular disease (CVD) and associated mortality, coronary heart disease (CHD) and associated mortality, ischemic stroke, and type 2 diabetes.
Design Systematic review and meta-analysis.
Data sources Medline, Embase, Cochrane Central Registry of Controlled Trials, Evidence-Based Medicine Reviews, and CINAHL from inception to 1 May 2015, supplemented by bibliographies of retrieved articles and previous reviews.
Eligibility criteria for selecting studies Observational studies reporting associations of saturated fat and/or trans unsaturated fat (total, industrially manufactured, or from ruminant animals) with all cause mortality, CHD/CVD mortality, total CHD, ischemic stroke, or type 2 diabetes.
Data extraction and synthesis Two reviewers independently extracted data and assessed study risks of bias. Multivariable relative risks were pooled. Heterogeneity was assessed and quantified. Potential publication bias was assessed and subgroup analyses were undertaken. The GRADE approach was used to evaluate quality of evidence and certainty of conclusions.
Results For saturated fat, three to 12 prospective cohort studies for each association were pooled (five to 17 comparisons with 90 501-339 090 participants). Saturated fat intake was not associated with all cause mortality (relative risk 0.99, 95% confidence interval 0.91 to 1.09), CVD mortality (0.97, 0.84 to 1.12), total CHD (1.06, 0.95 to 1.17), ischemic stroke (1.02, 0.90 to 1.15), or type 2 diabetes (0.95, 0.88 to 1.03). There was no convincing lack of association between saturated fat and CHD mortality (1.15, 0.97 to 1.36; P=0.10). For trans fats, one to six prospective cohort studies for each association were pooled (two to seven comparisons with 12 942-230 135 participants). Total trans fat intake was associated with all cause mortality (1.34, 1.16 to 1.56), CHD mortality (1.28, 1.09 to 1.50), and total CHD (1.21, 1.10 to 1.33) but not ischemic stroke (1.07, 0.88 to 1.28) or type 2 diabetes (1.10, 0.95 to 1.27). Industrial, but not ruminant, trans fats were associated with CHD mortality (1.18 (1.04 to 1.33) v 1.01 (0.71 to 1.43)) and CHD (1.42 (1.05 to 1.92) v 0.93 (0.73 to 1.18)). Ruminant trans-palmitoleic acid was inversely associated with type 2 diabetes (0.58, 0.46 to 0.74). The certainty of associations between saturated fat and all outcomes was “very low.” The certainty of associations of trans fat with CHD outcomes was “moderate” and “very low” to “low” for other associations.
Conclusions Saturated fats are not associated with all cause mortality, CVD, CHD, ischemic stroke, or type 2 diabetes, but the evidence is heterogeneous with methodological limitations. Trans fats are associated with all cause mortality, total CHD, and CHD mortality, probably because of higher levels of intake of industrial trans fats than ruminant trans fats. Dietary guidelines must carefully consider the health effects of recommendations for alternative macronutrients to replace trans fats and saturated fats.
PMCID: PMC4532752  PMID: 26268692
Despite its proven benefits and need, women’s access to cardiac rehabilitation (CR) is suboptimal. Referral strategies, such as systematic referral, have been advocated to improve access to CR. This study examined sex differences in CR referral and enrollment by referral strategies; and the impact of referral strategies for referral and enrollment concordance among women.
Prospective cohort study.
This prospective study included 2635 coronary artery disease inpatients from 11 Ontario hospitals that utilized 1 of 4 referral strategies. Participants completed a sociodemographic survey, and clinical data were extracted from charts. One year later, 1809 participants (452 [25%] women) completed a mailed survey that assessed CR utilization. Referral strategies were compared among women using generalized estimating equations to control for effect of hospital.
Overall, significantly more men than women were referred (67.2% and 57.8% respectively, p<.001), and enrolled in CR (58.6% and 49.3% respectively, p=.001). Of the retained women, combined systematic and liaison-facilitated referral resulted in significantly greater CR referral (Odds Ratio [OR]=10.3, 95% Confidence Interval [CI] = 4.11–25.58) and enrollment (OR=6.6, 95% CI = 4.34–9.92) among women when compared to usual referral. Conversely, concordance between referral and enrollment was greatest following usual referral (K=.85), and decreased with referral intensity.
While a lower proportion of referred patients enroll, systematic and liaison-facilitated inpatient referral strategies result in the greatest CR enrolment rates among women. Such strategies have the potential to improve access among women, and reduce “cherry picking” of patients for referral.
PMCID: PMC4522313  PMID: 23471593 CAMSID: cams4480
cardiac rehabilitation; cardiovascular diseases; health services accessibility; patient participation; referral; utilization
South Asians (SA) suffer an increased prevalence of coronary artery disease. Although cardiac rehabilitation (CR) is effective, SA are among the least likely to participate. ‘Automatic’ referral increases CR utilization and may reduce access inequalities.
This study qualitatively explored whether CR referral knowledge/access varied by referral method among SA patients. Participants were SA cardiac patients from Ontario hospitals. Each hospital refers to CR through one of four methods: automatically through paper or electronically; through discussion with allied health professionals (liaison referral); or through usual referral at physician discretion. Data was collected via interviews and analyzed using Interpretive-descriptive analysis.
Four themes emerged: 1) importance of pre-discharge CR discussions with health care providers; 2) limited knowledge of CR; 3) ease of referral process as facilitator of CR attendance; 4) participants’ need for personal autonomy over decision to attend CR.
Liaison referral was perceived to be the most suitable method of referral for participants. It facilitated communication between patients and providers, ensuring improved CR understanding. Automatic referral may be less suited for this population, due to reduced patient-provider communication.
PMCID: PMC4461376  PMID: 20450019 CAMSID: cams4487
Cardiac Rehabilitation; South Asian; Referral; Qualitative
BMC Genetics  2015;16:50.
Advances in genomics technology have led to a dramatic increase in the number of published genetic association studies. Systematic reviews and meta-analyses are a common method of synthesizing findings and providing reliable estimates of the effect of a genetic variant on a trait of interest. However, summary estimates are subject to bias due to the varying methodological quality of individual studies. We embarked on an effort to develop and evaluate a tool that assesses the quality of published genetic association studies. Performance characteristics (i.e. validity, reliability, and item discrimination) were evaluated using a sample of thirty studies randomly selected from a previously conducted systematic review.
The tool demonstrates excellent psychometric properties and generates a quality score for each study with corresponding ratings of ‘low’, ‘moderate’, or ‘high’ quality. We applied our tool to a published systematic review to exclude studies of low quality, and found a decrease in heterogeneity and an increase in precision of summary estimates.
This tool can be used in systematic reviews to inform the selection of studies for inclusion, to conduct sensitivity analyses, and to perform meta-regressions.
Electronic supplementary material
The online version of this article (doi:10.1186/s12863-015-0211-2) contains supplementary material, which is available to authorized users.
PMCID: PMC4431044  PMID: 25975208
Quality assessment; Genetic association studies; Genetic epidemiology
Yoneyama, Sachiko | Guo, Yiran | Lanktree, Matthew B. | Barnes, Michael R. | Elbers, Clara C. | Karczewski, Konrad J | Padmanabhan, Sandosh | Bauer, Florianne | Baumert, Jens | Beitelshees, Amber | Berenson, Gerald S. | Boer, Jolanda M.A. | Burke, Gregory | Cade, Brian | Chen, Wei | Cooper-Dehoff, Rhonda M. | Gaunt, Tom R. | Gieger, Christian | Gong, Yan | Gorski, Mathias | Heard-Costa, Nancy | Johnson, Toby | Lamonte, Michael J. | Mcdonough, Caitrin | Monda, Keri L. | Onland-Moret, N. Charlotte | Nelson, Christopher P. | O'Connell, Jeffrey R. | Ordovas, Jose | Peter, Inga | Peters, Annette | Shaffer, Jonathan | Shen, Haiqinq | Smith, Erin | Speilotes, Liz | Thomas, Fridtjof | Thorand, Barbara | Monique Verschuren, W. M. | Anand, Sonia S. | Dominiczak, Anna | Davidson, Karina W. | Hegele, Robert A. | Heid, Iris | Hofker, Marten H. | Huggins, Gordon S. | Illig, Thomas | Johnson, Julie A. | Kirkland, Susan | König, Wolfgang | Langaee, Taimour Y. | Mccaffery, Jeanne | Melander, Olle | Mitchell, Braxton D. | Munroe, Patricia | Murray, Sarah S. | Papanicolaou, George | Redline, Susan | Reilly, Muredach | Samani, Nilesh J. | Schork, Nicholas J. | Van Der Schouw, Yvonne T. | Shimbo, Daichi | Shuldiner, Alan R. | Tobin, Martin D. | Wijmenga, Cisca | Yusuf, Salim | Hakonarson, Hakon | Lange, Leslie A. | Demerath, Ellen W | Fox, Caroline S. | North, Kari E | Reiner, Alex P. | Keating, Brendan | Taylor, Kira C.
Human Molecular Genetics  2013;23(9):2498-2510.
Waist circumference (WC) and waist-to-hip ratio (WHR) are surrogate measures of central adiposity that are associated with adverse cardiovascular events, type 2 diabetes and cancer independent of body mass index (BMI). WC and WHR are highly heritable with multiple susceptibility loci identified to date. We assessed the association between SNPs and BMI-adjusted WC and WHR and unadjusted WC in up to 57 412 individuals of European descent from 22 cohorts collaborating with the NHLBI's Candidate Gene Association Resource (CARe) project. The study population consisted of women and men aged 20–80 years. Study participants were genotyped using the ITMAT/Broad/CARE array, which includes ∼50 000 cosmopolitan tagged SNPs across ∼2100 cardiovascular-related genes. Each trait was modeled as a function of age, study site and principal components to control for population stratification, and we conducted a fixed-effects meta-analysis. No new loci for WC were observed. For WHR analyses, three novel loci were significantly associated (P < 2.4 × 10−6). Previously unreported rs2811337-G near TMCC1 was associated with increased WHR (β ± SE, 0.048 ± 0.008, P = 7.7 × 10−9) as was rs7302703-G in HOXC10 (β = 0.044 ± 0.008, P = 2.9 × 10−7) and rs936108-C in PEMT (β = 0.035 ± 0.007, P = 1.9 × 10−6). Sex-stratified analyses revealed two additional novel signals among females only, rs12076073-A in SHC1 (β = 0.10 ± 0.02, P = 1.9 × 10−6) and rs1037575-A in ATBDB4 (β = 0.046 ± 0.01, P = 2.2 × 10−6), supporting an already established sexual dimorphism of central adiposity-related genetic variants. Functional analysis using ENCODE and eQTL databases revealed that several of these loci are in regulatory regions or regions with differential expression in adipose tissue.
PMCID: PMC3988452  PMID: 24345515
Respiratory diseases follow closely behind cardiovascular diseases in terms of global disease burden. Research investigating disparities in respiratory outcomes among specific populations in ethnically diverse countries, such as Canada, has been increasing, with the prevalence of asthma in Canada among the highest in the world. This study examined the prevalence of asthma and health care burden in groups that represent a significant proportion of Ontario’s population.
The South Asian and Chinese populations represent a significant portion of the population of Ontario; however, little is known about the burden of respiratory diseases in these populations.
To investigate the prevalence of asthma and the associated health care burden among South Asian and Chinese populations living in Ontario.
Using administrative health data for Ontario, the authors identified individuals of South Asian and Chinese descent using a validated surname algorithm and compared the prevalence of asthma in these groups with the general population using an established asthma case definition for the period 2002 to 2010. Also compared were the rates of asthma-specific emergency department visits and hospitalizations among the ethnic groups.
In 2010, the prevalence of asthma in South Asians residing in Ontario was similar to that of the general population (12.1% versus 12.4%), and was increasing at a faster rate than in the general population (0.51%/year versus 0.34%/year). Compared with the general population, the South Asian population had fewer emergency department visits for asthma, whereas the asthma-related hospitalization rate was greatest among the South Asian population (0.45 per 100 person-years). The Chinese population had the lowest asthma prevalence and associated health care use.
The burden of asthma among South Asians in Ontario is increasing and warrants further investigation to determine the reasons for this rise.
PMCID: PMC4266153  PMID: 25184509
Asthma; Epidemiology; Ethnicity
Scientific Reports  2015;5:9154.
Women have higher adiposity but maintain insulin sensitivity when compared to men. Phosphatase and tensin homolog deleted on chromosome 10 (PTEN) inhibits insulin signaling, but it is not known if PTEN regulate insulin resistance in a sex-specific manner. In this cross-sectional study, muscle biopsies from participants in the Molecular Study of Health and Risk in Ethnic Groups (Mol-SHARE) were used to test for sex differences in PTEN expression. Quantitative real-time PCR was performed to determine PTEN gene expression (n = 53), and western blotting detected total and phosphorylated PTEN protein (n = 36). Study participants were comparable in age and body mass index. Women had higher fat mass percentage compared to men (40.25 ± 9.9% in women versus 27.6 ± 8.8% in men; mean difference −0.18, 95%CI (−0.24, −0.11), p-value <0.0001), with similar HOMA-IR (2.46 ± 2.05 in men versus 2.34 ± 3.06 in women; mean difference 0.04; 95% CI (−0.12, 0.21), p-value 0.59). Women had significant downregulation of PTEN gene expression (p-value 0.01) and upregulation of PTEN protein phosphorylation (inactivation) (p-value 0.001) when compared to men after correction for age, ethnicity, HOMA-IR, fat mass and sex. We conclude that the downregulation of muscle PTEN may explain the retention of insulin sensitivity with higher adiposity in women compared to men.
PMCID: PMC4366049  PMID: 25777795
Diabetes Care  2013;36(9):2670-2676.
Many non-European ethnic groups have an increased risk for diabetes; however, the published literature demonstrates considerable uncertainty about the rates of diabetes complications among minority populations. The objective of this study was to determine the risks of cardiovascular complications and of mortality after diabetes diagnosis for South Asian and Chinese patients, compared with European patients.
A population-based cohort study identified all 491,243 adults with newly diagnosed diabetes in Ontario, Canada, between April 2002 and March 2009. Subjects were followed until March 2011 for the first occurrence of any cardiovascular complication of diabetes (coronary artery disease, stroke, or lower-extremity amputation) and for all-cause mortality. Median follow-up was 4.7 years.
The crude incidence of cardiovascular complications after diabetes diagnosis was 17.9 per 1,000 patient-years among European patients, 12.0 among South Asian patients, and 7.7 among Chinese patients. After adjusting for baseline characteristics, the cause-specific hazard ratios (HRs) for cardiovascular complications relative to European patients were 0.95 (95% CI 0.90–1.00; P = 0.056) and 0.50 (0.46–0.53; P < 0.001) for South Asian and Chinese patients, respectively. Mortality was lower for both minority groups (adjusted HR for South Asian patients 0.56 [95% CI 0.52–0.60]; P < 0.001; for Chinese patients 0.58 [0.55–0.62]; P < 0.001).
Chinese patients were at substantially lower risk than European patients for cardiovascular complications after diabetes diagnosis, whereas South Asian patients were at comparable risk. Mortality after diabetes diagnosis was markedly lower for both minority populations.
PMCID: PMC3747942  PMID: 23637350
Pharmacogenetics and genomics  2013;23(9):470-478.
The objective of this study was to identify genetic variants associated with angiotensin-converting enzyme (ACE) inhibitor-associated angioedema.
Participants and methods
We carried out a genome-wide association study in 175 individuals with ACE inhibitor-associated angioedema and 489 ACE inhibitor-exposed controls from Nashville (Tennessee) and Marshfield (Wisconsin). We tested for replication in 19 cases and 57 controls who participated in Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial (ONTARGET).
There were no genome-wide significant associations of any single-nucleotide polymorphism (SNP) with angioedema. Sixteen SNPs in African Americans and 41 SNPs in European Americans were associated moderately with angioedema (P<10−4) and evaluated for association in ONTARGET. The T allele of rs500766 in PRKCQ was associated with a reduced risk, whereas the G allele of rs2724635 in ETV6 was associated with an increased risk of ACE inhibitor-associated angioedema in the Nashville/Marshfield sample and ONTARGET. In a candidate gene analysis, rs989692 in the gene encoding neprilysin (MME), an enzyme that degrades bradykinin and substance P, was significantly associated with angioedema in ONTARGET and Nashville/Marshfield African Americans.
Unlike other serious adverse drug effects, ACE inhibitor-associated angioedema is not associated with a variant with a large effect size. Variants in MME and genes involved in immune regulation may be associated with ACE inhibitor-associated angioedema.
PMCID: PMC3904664  PMID: 23838604
adverse drug event; angioedema; angiotensin-converting enzyme; neprilysin
Diabetes Care  2013;36(9):2836-2842.
To determine if 16 single nucleotide polymorphisms (SNPs) associated with type 2 diabetes (T2DM) in Europeans are also associated with T2DM in South Asians and Latinos and if they can add to the prediction of incident T2DM in a high-risk population.
In the EpiDREAM prospective cohort study, physical measures, questionnaires, and blood samples were collected from 25,063 individuals at risk for dysglycemia. Sixteen SNPs that have been robustly associated with T2DM in Europeans were genotyped. Among 15,466 European, South Asian, and Latino subjects, we examined the association of these 16 SNPs alone and combined in a gene score with incident cases of T2DM (n = 1,016) that developed during 3.3 years of follow-up.
Nine of the 16 SNPs were significantly associated with T2DM, and their direction of effect was consistent across the three ethnic groups. The gene score was significantly higher among subjects who developed incident T2DM (cases vs. noncases: 16.47 [2.50] vs. 15.99 [2.56]; P = 0.00001). The gene score remained an independent predictor of incident T2DM, with an odds ratio of 1.08 (95% CI 1.05–1.11) per additional risk allele after adjustment for T2DM risk factors. The gene score in those with no family history of T2DM was 16.02, whereas it was 16.19 in those with one parent with T2DM and it was 16.32 in those with two parents with T2DM (P trend = 0.0004). The C statistic of T2DM risk factors was 0.708 (0.691–0.725) and increased only marginally to 0.714 (0.698–0.731) with the addition of the gene score (P for C statistic change = 0.0052).
T2DM genetic associations are generally consistent across ethnic groups, and a gene score only adds marginal information to clinical factors for T2DM prediction.
PMCID: PMC3747911  PMID: 23603917
Diabetologia  2014;57(11):2270-2281.
South Asians are up to four times more likely to develop type 2 diabetes than white Europeans. It is postulated that the higher prevalence results from greater genetic risk. To evaluate this hypothesis, we: (1) systematically reviewed the literature for single nucleotide polymorphisms (SNPs) predisposing to type 2 diabetes in South Asians; (2) compared risk estimates, risk alleles and risk allele frequencies of predisposing SNPs between South Asians and white Europeans; and (3) tested the association of novel SNPs discovered from South Asians in white Europeans.
MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and the Cochrane registry were searched for studies of genetic variants associated with type 2 diabetes in South Asians. Meta-analysis estimates for common and novel bi-allelic SNPs in South Asians were compared with white Europeans from the DIAbetes Genetics Replication And Meta-analysis (DIAGRAM) consortium. The population burden from predisposing SNPs was assessed using a genotype score.
Twenty-four SNPs from 21 loci were associated with type 2 diabetes in South Asians after meta-analysis. The majority of SNPs increase odds of the disorder by 15–35% per risk allele. No substantial differences appear to exist in risk estimates between South Asians and white Europeans from SNPs common to both groups, and the population burden also does not differ. Eight of the 24 are novel SNPs discovered from South Asian genome-wide association studies, some of which show nominal associations with type 2 diabetes in white Europeans.
Based on current literature there is no strong evidence to indicate that South Asians possess a greater genetic risk of type 2 diabetes than white Europeans.
Electronic supplementary material
The online version of this article (doi:10.1007/s00125-014-3354-1) contains peer-reviewed but unedited supplementary material, which is available to authorised users.
PMCID: PMC4180911  PMID: 25145545
Epidemiology; Ethnicity; Genetic risk; Meta-analysis; South Asian; Type 2 diabetes; White Europeans
CMAJ Open  2014;2(3):E183-E191.
South Asians represent about 3% of the Canadian population and have a higher burden of certain cardiovascular risk factors and cardiovascular disease (CVD) compared with white people. The objective of this study was to review the literature to compare cardiovascular risk factors and disease management practices among adult South Asian and white Canadians.
We searched MEDLINE, Embase, Cochrane and Cumulative Index to Nursing and Allied Health Literature databases from their inception through Feb. 17, 2014 and the reference lists of the selected articles. English-language studies of interventions and observational studies of biological mechanisms underlying CVD risk in South Asians conducted in Canada were eligible for inclusion. Where appropriate, we used random-effects meta-analyses to integrate results comparing the CVD risk profiles of South Asian and white Canadians.
We included 50 articles (n = 5 805 313 individuals) in this review. Compared with white Canadians, South Asian Canadians had a higher prevalence and incidence of CVD, an increased prevalence of diabetes (odds ratio [OR] 2.25, 95% confidence interval [CI] 1.81 to 2.80, p < 0.001) and hypertension (OR 1.11, 95% CI 1.02 to 1.22, p = 0.02), lower high-density lipoprotein cholesterol levels (mean difference –0.19 mmol/L, 95% CI –0.25 to –0.13 mmol/L, p < 0.001) and a higher percentage of body fat (men: absolute mean difference 3.23%, 95% CI 0.83% to 5.62%, p = 0.008; women: absolute mean difference 4.09%, 95% CI 3.46% to 4.72%, p < 0.001). South Asian people are also more sedentary, consume higher levels of carbohydrates and are less likely to smoke tobacco (OR 0.38, 95% CI 0.24 to 0.60, p < 0.001]) than white Canadians. No differences in access to diagnostic tests, outcomes following cardiovascular surgery or use of cardiac rehabilitation programs were apparent.
Compared with white people, South Asian people living in Canada have a higher prevalence and incidence of CVD and possess a unique cardiovascular risk profile.
PMCID: PMC4183167  PMID: 25295238
Household devices (e.g., television, car, computer) are common in high income countries, and their use has been linked to obesity and type 2 diabetes mellitus. We hypothesized that device ownership is associated with obesity and diabetes and that these effects are explained through reduced physical activity, increased sitting time and increased energy intake.
We performed a cross-sectional analysis using data from the Prospective Urban Rural Epidemiology study involving 153 996 adults from high, upper-middle, lower-middle and low income countries. We used multilevel regression models to account for clustering at the community and country levels.
Ownership of a household device increased from low to high income countries (4% to 83% for all 3 devices) and was associated with decreased physical activity and increased sitting, dietary energy intake, body mass index and waist circumference. There was an increased odds of obesity and diabetes with the ownership of any 1 household device compared to no device ownership (obesity: odds ratio [OR] 1.43, 95% confidence interval [CI] 1.32–1.55; diabetes: OR 1.38, 95% CI 1.28–1.50). Ownership of a second device increased the odds further but ownership of a third device did not. Subsequent adjustment for lifestyle factors modestly attenuated these associations. Of the 3 devices, ownership of a television had the strongest association with obesity (OR 1.39, 95% CI 1.29–1.49) and diabetes (OR 1.33, 95% CI 1.23–1.44). When stratified by country income level, the odds of obesity and diabetes when owning all 3 devices was greatest in low income countries (obesity: OR 3.15, 95% CI 2.33–4.25; diabetes: OR 1.97, 95% CI 1.53–2.53) and decreased through country income levels such that we did not detect an association in high income countries.
The ownership of household devices increased the likelihood of obesity and diabetes, and this was mediated in part by effects on physical activity, sitting time and dietary energy intake. With increasing ownership of household devices in developing countries, societal interventions are needed to mitigate their effects on poor health.
PMCID: PMC3940572  PMID: 24516093

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