Curcumin and type 2 diabetes mellitus : Prevention and treatment

Type 2 diabetes mellitus (T2DM) is an ensemble of metabolic diseases that has reached pandemic dimensions all over the world. The multifactorial nature of the pathology makes patient management, which includes lifelong drug therapy and lifestyle modification, extremely challenging. It is well known that T2DM is a preventable disease, therefore lowering the incidence of new T2DM cases could be a key strategy to reduce the global impact of diabetes. Currently, there is growing evidence on the efficacy of the use of medicinal plants supplements for T2DM prevention and management. Among these medicinal plants, curcumin is gaining a growing interest in the scientific community. Curcumin is a bioactive molecule present in the rhizome of the Curcuma longa plant, also known as turmeric. Curcumin has different pharmacological and biological effects that have been described by both in vitro and in vivo studies, and include antioxidant, cardio-protective, anti-inflammatory, anti-microbial, nephro-protective, anti-neoplastic, hepato-protective, immunomodulatory, hypoglycaemic and anti-rheumatic effects. In animal models, curcumin extract delays diabetes development, improves \u3b2-cell functions, prevents \u3b2-cell death, and decreases insulin resistance. The present review focuses on pre-clinical and clinical trials on curcumin supplementation in T2DM and discusses the peculiar mechanisms by which curcumin might ameliorate diabetes management

Nutritional management of lactose intolerance : the importance of diet and food labelling

Worldwide, 70% of the adult population has limited expression of lactase enzyme with a wide variation among different regions and countries. Lactase deficiency may lead to lactose intolerance (LI). Depending both on the amount of lactose ingested and on the lactase activity, people who suffer from lactose malabsorption might experience numerous gastrointestinal and extra-intestinal symptoms and manifestations. Treatment of LI mainly consists of reducing or eliminating lactose from the diet until the symptoms disappear as well as supplementing lactase, and inducing colon microbiome adaptation by probiotics. Cow's milk is one of the major source of calcium and several other vitamins and minerals. Thus, a complete exclusion of dairy products may favor the development of bone diseases such as osteopenia and osteoporosis. Therefore, the dietetic approach has a crucial role in the management of LI patients. Additionally, the use of lactose and milk-derived products in non-dairy products (e.g., baked goods, breakfast cereals, drinks, and processed meat) has become widespread in the modern industry (the so-called "hidden lactose"). In this regard, a strict adherence to the lactose-free diet becomes challenging for LI patients, forced to continuous check of all products and food labels. In fact, lactose-free product labeling is still controversial. Considering that nowadays a specific cut-off value establishing "lactose-free" labeling policy is lacking and that there is no universal law regulating the production and commercialization of "delactosed" products, identification of specific safe and suitable products with a well-recognized lactose-free logo might help consumers. This narrative review aims to identify the dietary management for lactose intolerant people, avoiding symptoms and nutrients deficiencies, helped by the use of specific labelling to guide them to choose the safer product on the market

Association of the chronotype score with circulating trimethylamine n‐oxide (Tmao) concentrations

Individual differences in the chronotype, an attitude that best expresses the individual circadian preference in behavioral and biological rhythms, have been associated with cardiometabolic risk and gut dysbiosis. Up to now, there are no studies evaluating the association between chronotypes and circulating TMAO concentrations, a predictor of cardiometabolic risk and a useful marker of gut dysbiosis. In this study population (147 females and 100 males), subjects with the morning chronotype had the lowest BMI and waist circumference (p < 0.001), and a better metabolic profile compared to the other chronotypes. In addition, the morning chronotype had the highest adherence to the Mediterranean diet (p < 0.001) and the lowest circulating TMAO concentrations (p < 0.001). After adjusting for BMI and adherence to the Mediterranean diet, the correlation between circulating TMAO concentrations and chronotype score was still kept (r = −0.627, p < 0.001). Using a linear regression analysis, higher chronotype scores were mostly associated with lower circulating TMAO concentrations (β = −0.479, t = −12.08, and p < 0.001). Using a restricted cubic spline analysis, we found that a chronotype score ≥59 (p < 0.001, R2 = −0.824) demonstrated a more significant inverse linear relationship with circulating TMAO concentrations compared with knots <59 (neither chronotype) and <41 (evening chronotype). The current study reported the first evidence that higher circulating TMAO concentrations were associated with the evening chronotype that, in turn, is usually linked to an unhealthy lifestyle mostly characterized by low adherence to the MD

Is HDL cholesterol protective in patients with type 2 diabetes? A retrospective population-based cohort study

Background: The protective role of high HDL cholesterol levels against cardiovascular diseases has been recently questioned. Limited data are available on this specific topic in patients with type 2 diabetes mellitus (T2DM). We aimed to evaluate the association of HDL cholesterol concentrations with all-cause and cause-specific mortality in a historical cohort of T2DM patients with 14 years of follow-up. Methods: This is a retrospective population-based cohort study involving 2113 T2DM patients attending the Diabetic Clinic of Asti. Survival analyses were performed to assess hazard ratios for overall and specific-cause mortality by HDL cholesterol tertiles, using the middle HDL cholesterol tertile as a reference. Results: The mean age was 66 \ub1 11 years; 51.4% of patients had low HDL-cholesterol levels. After a 14-year follow-up, 973/2112 patients had died (46.1%). The HDL cholesterol tertile cut-off points were 37.5 and 47.5 mg/dL (males) and 41.5 and 52.0 mg/dL (females). No associations between lower and upper HDL cholesterol tertiles respectively and all-cause (HR = 1.12; 95% CI 0.96-1.32; HR = 1.11; 0.95-1.30), cardiovascular (HR = 0.97; 0.77-1.23; HR = 0.94; 0.75-1.18) or cancer (HR = 0.92; 0.67-1.25; HR = 0.89; 0.66-1.21) mortality were found. A significantly increased risk for infectious disease death was found both in the lower (HR = 2.62; 1.44-4.74) and the upper HDL-cholesterol tertiles (HR = 2.05; 1.09-3.85) when compared to the reference. Individuals in the upper tertile showed an increased risk for mortality due to diabetes-related causes (HR = 1.87; 1.10-3.15). Conclusions: Our results corroborate the hypothesis that HDL cholesterol levels are nonprotective in T2DM patients. The U-shaped association between HDL-cholesterol levels and mortality associated with infectious diseases should be verified by further studies

Eating habits and lifestyle changes during COVID-19 lockdown : An Italian survey

Background: On December 12th 2019, a new coronavirus (SARS-Cov2) emerged in Wuhan, China, sparking a pandemic of acute respiratory syndrome in humans (COVID-19). On the 24th of April 2020, the number of COVID-19 deaths in the world, according to the COVID-Case Tracker by Johns Hopkins University, was 195,313, and the number of COVID-19 confirmed cases was 2,783,512. The COVID-19 pandemic represents a massive impact on human health, causing sudden lifestyle changes, through social distancing and isolation at home, with social and economic consequences. Optimizing public health during this pandemic requires not only knowledge from the medical and biological sciences, but also of all human sciences related to lifestyle, social and behavioural studies, including dietary habits and lifestyle. Methods: Our study aimed to investigate the immediate impact of the COVID-19 pandemic on eating habits and lifestyle changes among the Italian population aged 65 12 years. The study comprised a structured questionnaire packet that inquired demographic information (age, gender, place of residence, current employment); anthropometric data (reported weight and height); dietary habits information (adherence to the Mediterranean diet, daily intake of certain foods, food frequency, and number of meals/day); lifestyle habits information (grocery shopping, habit of smoking, sleep quality and physical activity). The survey was conducted from the 5th to the 24th of April 2020. Results: A total of 3533 respondents have been included in the study, aged between 12 and 86 years (76.1% females). The perception of weight gain was observed in 48.6% of the population; 3.3% of smokers decided to quit smoking; a slight increased physical activity has been reported, especially for bodyweight training, in 38.3% of respondents; the population group aged 18-30 years resulted in having a higher adherence to the Mediterranean diet when compared to the younger and the elderly population (p &lt; 0.001; p &lt; 0.001, respectively); 15% of respondents turned to farmers or organic, purchasing fruits and vegetables, especially in the North and Center of Italy, where BMI values were lower. Conclusions: In this study, we have provided for the first time data on the Italian population lifestyle, eating habits and adherence to the Mediterranean Diet pattern during the COVID-19 lockdown. However, as the COVID-19 pandemic is ongoing, our data need to be confirmed and investigated in future more extensive population studies

Glucagon-like peptide-1 receptor and sarcoglycan delta genetic variants can affect cardiovascular risk in chronic kidney disease patients under hemodialysis

Background Chronic kidney disease (CKD) patients under hemodialysis show a higher risk of cardiovascular (CV) mortality and morbidity than the general population. This study aims to identify genetic markers that could explain the increased CV risk in hemodialysis. Methods A total of 245 CKD patients under hemodialysis were recruited and followed up for 5\u2009years to record CV events. Genetic analysis was performed using single-nucleotide polymorphisms (SNPs) genotyping by Infinium Expanded Multi-Ethnic Genotyping Array (Illumina, San Diego, CA, USA) comparing patients with and without a history of CV events [161 cardiovascular diseases (CVDs) and 84 no CVDs]. The fixation index (Fst) measure was used to identify the most differentiated SNPs, and gene ontology analysis [Protein Analysis THrough Evolutionary Relationships (PANTHER) and Ingenuity Pathway Analysis (IPA)] was applied to define the biological/pathological roles of the associated SNPs. Partitioning tree analysis interrogated the genotype\u2013phenotype relationship between discovered genetic variants and CV phenotypes. Cox regression analysis measured the effect of these SNPs on new CV events during the follow-up (FU). Results Fst analysis identified 3218 SNPs that were significantly different between CVD and no CVD. Gene ontology analysis identified two of these SNPs as involved in cardiovascular disease pathways (Ingenuity Pathway) and heart development (Panther) and belonging to 2 different genes: Glucagon-like peptide-1 receptor (GLP1R) and Sarcoglycan delta (SGCD). The phenotype\u2013genotype analysis found a higher percentage of CVD patients carrying the GLP1R rs10305445 allele A (P\u2009=\u20090.03) and lower percentages of CVD patients carrying the SGCD rs145292439 allele A (P\u2009=\u20090.038). Moreover, SGCD rs145292439 was associated with higher levels of high-density lipoprotein (P\u2009=\u20090.015). Cox analysis confirmed the increased frequency of CV events during the 5-year FU in patients carrying GLP1R rs1035445 allele A but it did not show any significant association with SGCD rs145292439. Conclusions This study identified GLP1R rs10305445 and SCGD rs145292439 as potential genetic markers that may explain the higher risk of CVD in hemodialysis patients

GENETIC, BIOCHEMICAL AND NUTRITIONAL MARKERS OF CARDIOVASCULAR EVENTS IN CHRONIC KIDNEY DISEASE PATIENTS

Introduzione. I pazienti con insufficienza renale cronica (IRC) sono ad alto rischio di mortalit\ue0 cardiovascolare, superiore rispetto alla popolazione generale della stessa et\ue0. Infatti, la malattia cardiovascolare \ue8 la prima causa di morte nei pazienti affetti da IRC, a causa della presenza dei classici fattori di rischio insieme ai rischi specifici della patologia renale, come i disturbi del metabolismo minerale osseo. Le complicanze a lungo termine includono iperparatiroidismo e iperfosfatemia, legati ad un aumento del livello sierico di FGF23 (Fibroblast Growth Factor 23). FGF23 \ue8 un fattore di crescita prodotto dal tessuto osseo che agisce sulla riduzione della fosfatemia. La letteratura riporta che una prolungata esposizione all'assunzione di fosfato aumenta la produzione di FGF23. I dati mostrano un legame tra FGF23 e iperfosfatemia, con il conseguente aumento del rischio cardiovascolare. Una restrizione dietetica del fosfato pu\uf2 essere una strategia contro la morbilit\ue0 cardiovascolare e la formazione di calcificazioni vascolari. Un altro interessante marker del metabolismo osseo \ue8 la sclerostina, una proteina prodotta dagli osteociti ad attivit\ue0 inibitoria sull\u2019osteogenesi e la sua produzione \ue8 aumentata nell\u2019IRC. L'attuale studio si propone di indagare la mortalit\ue0 e la morbilit\ue0 cardiovascolare identificando marcatori genetici, biochimici e funzionali. Il progetto \ue8 uno studio osservazionale longitudinale e i pazienti reclutati sono stati seguiti per un follow-up di 5 anni. Sono stati studiati la predisposizione genetica al rischio di insorgenza di eventi cardiovascolari nell\u2019IRC e i fattori nutrizionali e biochimici che potrebbero influenzare lo sviluppo e la progressione degli eventi cardiovascolari in questi pazienti. Popolazione e Metodi. L'attuale studio ha reclutato 332 pazienti affetti da IRC, sia in pre-dialisi che in emodialisi (HD) e ha raccolto i recall dietetici delle 24 ore, storia medica, parametri biochimici e strumentali e campioni di sangue per le analisi genetiche. La genotipizzazione degli SNPs \ue8 stata eseguita su 208 pazienti in HD utilizzando Illumina\uae MegaEX Array (SNP 2M) confrontando i pazienti con precedenti eventi cardiovascolari (CV1, 135 soggetti) con pazienti senza eventi cardiovascolari (CV0, 73 soggetti). Per ciascun marker \ue8 stato calcolato l'indice di fissazione (Fst) utilizzando CV1 e CV0 come sottopopolazioni al fine di identificare gli SNPs pi\uf9 differenziati tra i due sottogruppi. Utilizzando il cut-off del 99\ub0 percentile della distribuzione Fst, sono stati identificati 3218 SNPs come differenziati tra CV1 e CV0. Sono stati interrogati due strumenti di pathway funzionale (Panther and Ingenuity Pathway Analysis - IPA) per definire qualsiasi possibile ruolo biologico/patologico degli SNPs associati. Risultati. \uc8 stato osservato che i pazienti in HD hanno peso corporeo, calcemia e vitamina D inferiori e fosfatemia, PTH e FGF23 pi\uf9 elevati rispetto ai pazienti pre-dialisi con IRC allo stadio 3-5. Inoltre, la regressione lineare multipla mostra una relazione positiva tra fosfatemia, FGF23 e PTH in entrambi i pazienti HD e pre-dialisi, mentre \ue8 stata trovata una relazione negativa tra l'assunzione di fosfato e la fosfatemia. Probabilmente questo \ue8 dovuto all'effetto di FGF23. Il campione di soggetti \ue8 stato poi diviso in tre gruppi in base all'assunzione di fosfato. Per i pazienti in HD il livello sierico di FGF23 aumenta all\u2019aumentare dell\u2019assunzione di fosfato, mentre nei pazienti in pre-dialisi questa relazione non viene osservata. Inoltre, sono stati valutati i fattori di rischio legati alle malattie cardiovascolari. Un'analisi di regressione (Cox) sul campione ha dimostrato che un'assunzione elevata di fosfato nella dieta (>1200 mg/die) aumenta il rischio di eventi cardiovascolari. La sclerostina sierica, invece, \ue8 aumentata in 87 pazienti con IRC e il suo aumento era proporzionale al declino del tasso di filtrazione glomerulare (GFR). Considerando i terzili di sclerostina sierica, i pazienti nel terzile pi\uf9 alto hanno mostrato valori di GFR e di vitamina D inferiori e valori pi\uf9 elevati di FGF23 rispetto ai pazienti nel terzile pi\uf9 basso. Lo z-score osseo lombare (BMD) era maggiore nei pazienti nei terzili pi\uf9 alti e nel terzile medio, considerati insieme, rispetto ai pazienti nel terzile pi\uf9 basso. I pazienti che non assumevano calcitriolo come terapia cronica (n=60) avevano valori di GFR pi\uf9 alti e sclerostina sierica inferiore rispetto ai pazienti trattati cronicamente con calcitriolo. La regressione multipla ha mostrato che la sclerostina sierica era negativamente associata alla vitamina D e positivamente a FGF23 nell'intero campione e nei pazienti che non assumevano calcitriolo. Anche questa analisi ha mostrato che solo la sclerostina sierica era positivamente associata allo z-score della BMD in tutti i partecipanti e nei pazienti che non assumevano calcitriolo. Lo score di calcificazione dell'aorta e gli eventi cardiovascolari non erano associati alla sclerostina sierica. Per l'analisi genetica, sono stati uniti i risultati pi\uf9 significativi dei due strumenti di analisi e identificati due geni coinvolti in entrambi i pathway di malattia cardiovascolare (da IPA) e nello sviluppo del cuore (Panther): il recettore del peptide-1 simile al glucagone (GLP1R) e il delta Sarcoglicano (SGCD). Usando la tree regression analysis \ue8 stato scoperto che l'allele minore GLP1R rs10305445 \ue8 associato a percentuali pi\uf9 alte di CV1 (p=0.03) e, inversamente, l'allele minore SGCD rs145292439 \ue8 associato a percentuali pi\uf9 basse di CV1 (p=0.038) e livelli pi\uf9 elevati di HDL (p=0.015). La valutazione nutrizionale \ue8 stata condotta su 148 soggetti (98 in HD e 50 in pre-dialisi). Le analisi hanno mostrato una correlazione positiva tra lo stadio della malattia e l'assunzione di vitamina E, mentre aveva una correlazione negativa con l'assunzione di beta-carotene. Tuttavia, non sono state osservate correlazioni significative tra l'analisi dei dati nutrizionali raccolti e le analisi genetiche condotte. Conclusioni. I livelli sierici di FGF23 aumentano con un'elevata assunzione di fosfato nella dieta (> 1200 mg/die) nei pazienti in HD. I pazienti in HD hanno un pi\uf9 alto apporto di fosfato rispetto ai pazienti affetti da IRC allo stadio 3-5. I valori di FGF23 sono principalmente influenzati dall'assunzione di fosfato con il cibo nei pazienti in HD. In particolare, un'assunzione elevata di fosfati nella dieta (>1200 mg/die) aumenta il rischio di eventi cardiovascolari durante tutti gli stadi della IRC. Inoltre, i nostri risultati suggeriscono che la sclerostina sierica possa essere un determinante della sintesi di vitamina D e possa predire la massa ossea nei pazienti affetti da IRC. Da questa analisi preliminare, \ue8 possibile concludere che i fattori genetici possono contribuire pi\uf9 della dieta nello sviluppo di malattie cardiovascolari nei pazienti con IRC ed ipotizzare GLP1R come marcatore genetico di rischio e SGCD come marcatore protettivo per IRC. Rimangono da investigare i meccanismi che si nascondono sotto queste varianti alleliche e che influenzano le vie metaboliche specifiche associate alla malattia cardiovascolare nella IRC.Introduction. Chronic Kidney Disease (CKD) patients at different stages suffer of high risk of cardiovascular mortality, which is higher than the age-matched general population. In fact, cardiovascular disease (CVD) is the first cause of death in CKD patients because of the simultaneous presence of the classical risk factors and the ones specific of the renal disease, among which there are metabolic mineral disorders. The long-term complications include hyperparathyroidism and hyperphosphatemia that are linked to an increase of FGF23 (Fibroblast Growth Factor 23) serum level. FGF23 is a growth factor produced by the bone tissue that acts to reduce the level of serum phosphate. Literature reports that a prolonged exposure to phosphate intake increases FGF23 production. Data show a link between FGF23 and hyperphosphatemia with an increased risk of CVD. A dietary restriction of phosphate can be useful to fight against cardiovascular morbidity and vascular calcifications. Another interesting bone metabolism marker is sclerostin, a protein produced by osteocytes having an inhibitory activity on bone formation and its production is increased in CKD patients. The current study is called "The Cardiovascular Mortality project: study of functional markers" (CREMA) and aims to investigate cardiovascular mortality by identifying the genetic, biochemical and functional markers of arterial damage in relation to the diet. The project is a longitudinal observational study. Recruited patients were followed for a 5-year follow-up period. The main purpose of the study was to identify the genetic factors predisposing the risk of occurrence of cardiovascular events in CKD and, together with these, the nutritional and biochemical factors that could influence the development and progression of cardiovascular events. Population and Methods. The current study recruited 332 CKD patients, both in pre-dialysis and in hemodialysis (HD) and collected dietary 24hrs recalls, medical history, biochemical and instrumental parameters and blood samples for genetic analysis. SNPs genotyping was performed in 208 HD patients using Illumina\uae MegaEX Array (2M SNPs) comparing patients with previous cardiovascular events (CV1; 135 subjects) to patients without cardiovascular events (CV0; 73 subjects). For each marker, we calculated the Fixation Index (Fst) using the CV1 and CV0 as subpopulations in order to identify the most differentiated SNPs between the two subgroups. Using the cut-off of the 99th percentile of the Fst distribution we identified 3218 SNPs as differentiated between CV1 and CV0. We interrogated two functional pathway tools (Panther and Ingenuity Pathway Analysis - IPA) to define any possible biological/pathological role of the associated SNPs. Results. We observed that HD patients had lower body weight, lower calcium and lower vitamin D serum and higher phosphatemia, PTH and FGF23 than pre-dialysis CKD patients at stage 3-5. Multiple linear regression showed positive correlation between serum phosphate, FGF23 and PTH in both HD and pre-dialysis CKD patients, while a negative correlation between phosphorous intake and serum phosphate was found. Probably this is due to the effect of FGF23. The sample was split in three sets based on phosphate intake. Serum FGF23 was evaluated for the three sets. For HD patients, FGF23 serum level increases with an increase of phosphate, whereas in pre-dialysis CKD patients this relation is not observed. Moreover, risk factors linked to CVD were evaluated for our sample. A Cox regression analysis on the sample showed that a high dietary phosphate intake (> 1200 mg/die) increases the risk of cardiovascular events. Serum sclerostin was increased in 87 patients with CKD and its increase was proportional to estimated glomerular filtration rate (eGFR) decline. Considering tertiles of serum sclerostin, patients in the highest tertile showed lower GFR and 1,25(OH)2D serum values and higher FGF23 serum values than in patients in the lowest tertile. Lumbar-spine bone mineral density (BMD) z-score was greater in patients in the highest and the middle tertiles, taken together, than in patients in the lowest tertile. Patients not-taking calcitriol as chronic therapy (n=60) had higher eGFR and lower serum sclerostin than patients chronically treated with calcitriol. Multiple stepwise regression showed that serum sclerostin was negatively associated with serum 1,25(OH)2D and positively with serum FGF23 in the whole patient sample and in patients not-taking calcitriol. Multiple stepwise regression also showed that only serum sclerostin was positively associated with BMD z-score in all participants and patients not-taking calcitriol. Aorta calcification score and cardiovascular events were not associated with serum sclerostin. For the genetic analysis, we merged the most significant results from the two tools and we identified two genes involved in both cardiovascular disease pathways (from IPA) and hearth development (Panther): Glucagon-like peptide-1 receptor (GLP1R) and Sarcoglycan delta (SGCD). Using regression tree analysis, we found that GLP1R rs10305445 minor allele A is associated with higher percentages of CV1 (p=0.03) and, inversely, SGCD rs145292439 minor allele A is associated with lower percentages of CV1 (p=0.038) and higher levels of HDL (p=0.015). Nutrition evaluation was conducted on 148 subjects (98 in hemodialysis and 50 in pre-dialysis). The analyses showed a positive correlation between the stage of the disease and the intake of vitamin E, while it had a negative correlation with beta-carotene intake. However, no significant correlations have been observed between the analysis of the collected nutritional data and the conducted genetic analyses. Conclusions. Serum FGF23 levels increase with high dietary phosphate intake (>1200 mg/die) in HD patients. HD patients have a higher intake of phosphate than pre-dialysis CKD patients at stage 3-5. FGF23 is mainly influenced by phosphate dietary intake in hemodialysis patients. Moreover, a high dietary phosphate intake (>1200 mg/die) increases the risk of cardiovascular events during all stages of CKD. Our findings suggest that serum sclerostin may be a determinant of 1,25(OH)2D synthesis and may predict bone mass in CKD patients. From this preliminary analysis, we can conclude that the genetic factors may contribute more than diet to cardiovascular disease in CKD patients and we can speculate a role of GLP1R as genetic risk marker and SGCD as protective marker. The mechanisms hiding under these allelic variants influence the specific metabolic pathways associated with cardiovascular disease in CKD remain to be investigated. Further studies are needed to evaluate the impact of vitamin E and beta-carotene on CKD

The Cardiovascular Burden in End-Stage Renal Disease

It is well documented that chronic kidney disease patients have an extremely high risk of developing cardiovascular (CV) disease (CVD) compared to the general population. Declining renal function itself represents a continuum of CV risk, and in those individuals who survive to reach end-stage renal disease, the risk of suffering a cardiac event is uncomfortably and unacceptably high. Several pathophysiological pathways have been suggested to account for this, including endothelial dysfunction, dyslipidemia, inflammation, left ventricular hypertrophy, troponins, phosphate, vitamin D, fibroblast growth factor-23, and NT-proBNP. All these conditions and biomarkers may have clear associations with current and subsequent CVD