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larger RBC EPA + DHA corresponds with greater complete mind and hippocampal volumes | A00-280 boot camp and PDF Questions

Neurology. 2014 Feb four; eighty two(5): 435–442.

WHIMS-MRI examine

James V. Pottala, PhD,corresponding authorKristine Yaffe, MD, Jennifer G. Robinson, MD, MPH, Mark A. Espeland, PhD, Robert Wallace, MD, MSc, and William S. Harris, PhD

From the branch of interior medication (J.V.P., W.S.H.), Sanford faculty of drugs, university of South Dakota, Sioux Falls; fitness Diagnostic Laboratory Inc. (J.V.P., W.S.H.), Richmond, VA; branch of Psychiatry (k.Y.), tuition of California scientific middle, San Francisco; Departments of Epidemiology and inner medicine (J.R., R.W.), college of Iowa faculty of Public fitness, Iowa metropolis; branch of Biostatistical features (M.A.E.), Wake woodland school of drugs, Winston-Salem, NC; and OmegaQuant Analytics (W.S.H.), Sioux Falls, SD.

The short checklist of WHI Investigators is purchasable on the Neurology® net web site at www.neurology.org. Go to Neurology.org for full disclosures. Funding advice and disclosures deemed primary via the authors, if any, are supplied at the conclusion of the article.

bought 2013 may 14; authorized 2013 Oct 24.

Copyright © 2014 American Academy of Neurology this text has been mentioned by means of other articles in PMC. Supplementary materials

statistics supplement

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GUID: 76FF2D6D-D0F1-4BC8-95B5-15FC004B8A5C

summary goal:

To look at various whether red blood phone (RBC) ranges of marine omega-three fatty acids measured in the ladies's health Initiative reminiscence look at had been related to MRI brain volumes measured 8 years later.


RBC eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), and MRI mind volumes had been assessed in 1,111 postmenopausal women from the women's health Initiative memory look at. The endpoints were complete brain extent and anatomical areas. Linear blended models covered distinctive imputations of fatty acids and have been adjusted for hormone remedy, time seeing that randomization, demographics, intracranial extent, and cardiovascular disease possibility components.


In completely adjusted models, a 1 SD more suitable RBC EPA + DHA (omega-3 index) degree turned into correlated with 2.1 cm3 bigger mind volume (p = 0.048). DHA became marginally correlated (p = 0.063) with complete brain extent whereas EPA turned into much less so (p = 0.11). there have been no correlations between ischemic lesion volumes and EPA, DHA, or EPA + DHA. A 1 SD superior omega-three index changed into correlated with enhanced hippocampal quantity (50 mm3, p = 0.036) in wholly adjusted models. comparing the fourth quartile vs the first quartile of the omega-3 index confirmed more desirable hippocampal volume (159 mm3, p = 0.034).


a stronger omega-3 index turned into correlated with larger complete common brain quantity and hippocampal volume in postmenopausal ladies measured eight years later. while general growing old outcomes in normal mind atrophy, lower omega-three index can also signal extended possibility of hippocampal atrophy. Future reports should check whether retaining larger RBC EPA + DHA degrees slows the price of hippocampal or universal brain atrophy.

growing older is associated with expanded possibility of dementia and cognitive impairment, with exponentially increasing occurrence expected within the subsequent a couple of decades.1 in keeping with data from the Framingham look at, a center-aged lady in North america of European descent has approximately 20% chance of setting up dementia of some type in her lifetime, which continually contains Alzheimer ailment (advert).2 reduced mind extent is an important part of the pathology of advert, and hippocampal atrophy is often observed earlier than symptomatic impairment.3

Omega-3 fatty acids (FAs) from marine sources could have a vital role in retaining mind constitution and function with advancing age. approximately 30% to forty% of FAs in grey count number of the cortex are docosahexaenoic acid (DHA),four and this FA is peculiarly centred in synaptic membranes.5 despite the fact, in white matter, DHA constitutes handiest four% of complete FAs.6 sufferers with ad were pronounced to have reduced serum, brain, and neuronal DHA and/or eicosapentaenoic acid (EPA) in comparison with controls without dementia.7,–11 DHA degrees inside plasma phosphatidylcholine, in the maximum quartile, were linked to a forty% to 50% reduction in chance of setting up all-trigger dementia or advert in the long-established Framingham cohort.12 Most central to the latest study, total brain volumes had been without delay related to RBC omega-3 ranges in the Framingham Offspring cohort.13 In their analyze, they hypothesized that marine omega-3 FAs could be without delay regarding complete mind volumes determined with the aid of MRI 8 years later, after which explored the members of the family in ischemic tissue and 13 gray and white remember anatomical areas.

methods MRI facts.

The MRI standardized protocol has been described up to now,14,–16 and is in short reported here: T1-weighted, T2-weighted, proton density–weighted, and fluid-attenuated inversion recuperation scans were acquired from each individual. The multimodality images had been coregistered with the aid of typical protocol, extracranial material turned into eliminated, and the T1-weighted mind tissue masks become used for segmentation into grey and white count number and CSF. Anatomical place (i.e., four lobes, limbic, basal ganglia, corpus callosum, hippocampus) volumetric measurements were got using an automated laptop-based mostly template warping formula that summed the variety of respective voxels.17 Intracranial extent turned into estimated as total cerebral hemispheric volumes plus the ventricular CSF. Ischemic lesion extent segmentation used a guide vector laptop classifier educated on expert-defined lesions that has been validated in different reviews.16,18,19

RBC FA evaluation.

during this study, RBC FA composition became analyzed the usage of gasoline chromatography with flame ionization detection, and expressed as a weight % of total recognized FAs.20 The omega-three index was described as EPA + DHA, which is a documented marker of omega-3 biostatus.21 The intra-assay coefficient of model for EPA + DHA was 1.6% and nil.8% for the low and excessive controls, respectively; the interassay coefficient of variation changed into three.eight% and 1.7%. all through the aliquoting part, the RBC samples had been saved improperly at −20°C for a length of approximately 2 weeks, inflicting oxidative degradation of the polyunsaturated FA before dimension. The common FA tiers were estimated with multiple imputations using unbiased facts on FA degradation costs and the length of time the samples were exposed to −20°C.20 After correcting the bias within the complete ladies's fitness Initiative memory analyze (WHIMS) cohort, 3.1% of samples remained severely degraded and have been advised for exclusion in subsequent analyses.20 In their MRI cohort, 63 subjects were thus excluded.


All subjects were participants in the girls's fitness Initiative (WHI) randomized, placebo-controlled medical trial to verify the outcomes of hormone remedy (HT) (conjugated equine estrogen remedy [0.625 mg/d] with or with out medroxyprogesterone acetate [2.5 mg/d]) on fundamental results of coronary heart sickness and breast melanoma. A subset turned into covered within the WHIMS, which examined the consequences of HT on loss of cognitive characteristic.22,23 on the time of enrollment in WHIMS, the subjects had been sixty five to 80 years of age and freed from dementia.24 an additional subset changed into recruited from 14 of the 39 US analysis facilities to take part within the WHIMS mind MRI examine.14 These ladies had a regular age (range) of seventy eight years (seventy one–88) at the time of MRI.

there have been 1,380 women with RBC FA and MRI information. The WHI screening visits, when blood samples had been accumulated, took place from 1995 to 1998. The MRI brain scans have been carried out a median of eight.0 years after blood become drawn. Sixty-three subjects had been excluded as a result of their RBC samples were degraded as defined above.20 there have been 38 subjects who experienced a stroke or TIA between the screening talk over with and the MRI mind scans; as a result of these routine may have altered MRI effects unbiased of FA publicity, they were additionally excluded. An further 168 members have been excluded as a result of poor exceptional scans (27) or missing variables critical to the evaluation (141). for this reason, the entire number of girls covered during this analysis became 1,111. All analyses have been carried out for each FA imputation, and then the inferences have been combined the usage of Rubin's approach.25

regular protocol approvals, registrations, and patient concurs.

All individuals gave written recommended consent, and institutional assessment boards authorised the study protocols.

Statistical strategies.

Bivariate members of the family that quartiles of standard and ischemic brain volumes had with medical components had been demonstrated using 1-means evaluation of variance and χ2 assessments for continual and categorical facts, respectively. Racial transformations were controlled for with the aid of forming the quartiles independently for white and nonwhite subjects, after which combining the corporations.

Volumes in cubic centimeters of complete, general, and herbal logarithm of ischemic lesions were the stylish variables in linear combined fashions. The fundamental speculation was that total brain extent would be linked to the omega-3 index; the component FAs DHA and EPA have been also assessed in my view. Three levels of covariate adjustment were decided a priori. the primary mannequin protected examine design variables (i.e., HT treatment assignment, time from randomization to MRI scan, and a covariance element changed into protected to mannequin the potential correlation from clusters of subjects inside clinical websites) and stuck covariates (i.e., age, intracranial quantity, race, and highest stage of training acquired). education is a hallmark of socioeconomic reputation, which may also be considered a fixed aspect for this cohort of postmenopausal ladies. A second mannequin moreover adjusted for modifiable, environmental factors (i.e., current smoking, physical endeavor, alcohol intake, and physique mass index), and disease comorbidities (i.e., prior cardiovascular disease, diabetes, and treated and untreated hypertension). The third model covered all blood biomarkers acquired on the WHI screening talk over with, i.e., excessive-density lipoprotein (HDL) ldl cholesterol, non-HDL cholesterol, triglycerides, C-reactive protein (CRP), creatinine, insulin, and glucose. Triglycerides, CRP, insulin, and glucose had correct-skewed distributions in order that they have been modified the use of a natural logarithm to cut back leverage of extreme values. lastly, an interaction changed into confirmed between the omega-3 index and HT medication assignment the use of the Wald look at various.

In an exploratory analysis, the family members between the omega-three index and 13 anatomical regions (5 white matter and eight gray matter) have been analyzed in absolutely adjusted models. As a sensitivity analysis, the omega-3 index turned into covered as a continuous and ordinal (i.e., quartiles) variable in separate fashions. A critical level ≤0.05 become used for trying out the primary hypothesis and for the regional exploratory analyses; for the univariate evaluation, the vital stage changed into managed at 0.05 the use of Bonferroni correction. Analyses had been carried out using SAS application (version 9.three; SAS Institute Inc., Cary, NC).


On common, normal and ischemic tissue constituted 99% and 1% of the overall mind volume, respectively. standard, the tissue was fifty six% white count and forty four% gray remember; shows the distribution of white and gray count number by means of anatomical place. indicates the demographic and clinical elements linked to quartiles of normal mind volumes, and table e-1, on the Neurology® internet web site at www.neurology.org, indicates the ischemic brain volumes with the aid of quartiles. Older age became directly regarding the extent of ischemic lesion quantity and inversely to volume of general brain tissue. Intracranial quantity become directly regarding both ordinary and ischemic tissue volumes. within the bivariate analyses, there were no enormous family members between the omega-three index, DHA or EPA, and standard or ischemic mind volumes. however, elements that vary between omega-three index quartiles may confound the relation between the index and mind volumes; these include training, physical recreation, physique mass index, CRP, HDL cholesterol, and triglycerides (table e-2).

suggest regular (A) and ischemic (B) lesion brain volumes in cubic centimeters by anatomical location

desk 1

patient qualities via quartiles of general (i.e., nonischemic) brain volume (stratified by way of race)

DHA, EPA, and their sum (i.e., the omega-3 index) had been validated in separate models as predictor variables of complete brain volume, and the elements of general and ischemic tissue with three models of covariate adjustment. within the completely adjusted mannequin, complete mind extent turned into at once concerning the omega-three index (p = 0.048); a 1-SD boost changed into linked to 2.1 cm3 (95% self assurance interval: 0.0–four.3 cm3) higher mind quantity (). essentially similar effects had been bought in standard brain extent. The association between a 1-SD boost in DHA become marginally massive (2.0 cm3 for each, p = 0.063 and nil.059) with complete and normal brain extent, respectively; youngsters, EPA turned into now not tremendously linked in wholly adjusted models (1.7 and 1.6 cm3, p = 0.11 and zero.15, respectively). there have been no associations between the herbal logarithm of ischemic lesion volumes and any of the omega-3 FA metrics. there were additionally no massive interactions between the omega-3 index and HT on total or common brain volumes (p = 0.41 and nil.32, respectively).

desk 2

Associations between brain volumes and a 1-SD enhance in RBC omega-three fatty acids (N = 1,111)

subsequent, the affiliation of the omega-3 index with usual brain quantity was explored in 13 anatomical regions, together with 5 white rely (i.e., the 4 lobes and corpus callosum) and eight grey count (i.e., the four lobes, basal ganglia, limbic system, hippocampus, and parahippocampal gyrus). In totally adjusted fashions, the omega-three index turned into covered as both a continual variable (per 1 SD = 1.6%) or by evaluating the fourth quartile (q4) vs the primary quartile (Q1), which had mean levels of seven.5% vs 3.four%. In white matter, a 1-SD raise within the index turned into linked to a 66 mm3 (95% self assurance interval: 1–one hundred thirty mm3) better corpus callosum (). youngsters, the corpus callosum quantity turned into no longer different between this autumn and Q1 (p = 0.16). In gray depend, the hippocampus turned into at once related to the omega-three index on both a per-SD basis (50 mm3, p = 0.036; ) and comparing this autumn and Q1 (159 mm3, p = 0.034).

table 3

Associations between general (i.e., nonischemic) brain volumes (cm3) and the omega-3 index, in completely adjusted models (N = 1,111)

imply typical hippocampal brain quantity in cubic centimeters by omega-3 index the usage of linear regression with 95% self assurance bands

The fully adjusted model has a a little bit attenuated slope compared with the unadjusted mannequin, but decreased variability; a three.2% more desirable omega-three index is correlated with 100 mm3 enhanced hippocampus volume (p = 0.036). DHA = docosahexaenoic acid; EPA = eicosapentaenoic acid; RBC = crimson blood cellphone.


We found that a 2 SD (3.2% absolute) greater omega-three index became linked to a 0.forty eight% (four.2 cm3) larger complete brain extent measured eight years later. The 4.1% absolute imply difference between Q1 and q4 within the omega-3 index stage was associated with a 0.sixty seven% (5.8 cm3) better mind quantity. in a similar fashion, within the Framingham Offspring cohort (n = 1,575, 54% ladies, commonplace age 67 years), individuals with an omega-3 index within the first quartile had a smaller typical brain extent (−0.49%) in comparison with those in the upper 3 quartiles, which was described as being similar to about 2 years of ordinary mind getting older.13

In their multicenter, girls-simplest analyze, they discovered no family members between ischemic lesion volumes (which represented each diffuse small-vessel disease and the hyperintensities that surround focal lesions) and marine omega-3 FAs. this is in contrast to the Framingham look at, which said superior white rely hyperintensity volumes as a percent of intracranial extent with lessen DHA levels.13 A plasma nutrient biomarker pattern that included EPA, DHA, and 12 different nutrients become additionally inversely related to white rely hyperintensity volumes.e1 The Cardiovascular fitness examine (n = 2,465, 59% girls, common age 75 years) pronounced much less chance of subclinical infarcts, described as ischemic lesions ≥three mm in diameter, for contributors who ate fatty, nonfried fish more often.26

In a old look at with 192 men and ladies (average age 78 years), the mean lower in complete mind extent was −0.45% and −0.ninety eight% per year in subjects without and with dementia, respectively, over a normal of two years observe-up.27 curiously, they additionally discovered that the slope of the cross-sectional relationship between age and mind volumes in subjects without dementia was akin to the longitudinal rate of exchange. Their cohort blanketed more than 1,one hundred women sixty five years or older and free of dementia at WHIMS screening, and only 1 girl who developed dementia participated within the MRI study.

We also found that larger levels of RBC EPA + DHA were linked to larger hippocampal volumes, however big alterations have been no longer detected in different particular regions between the upper and lessen quartiles of the index. as a result of their examine was go-sectional, they cannot examine even if the volumetric changes present in the hippocampus would be suggestive of early neurodegenerative pathology. In a analyze of fifty five men and girls with a median age of forty five years, the maximum tertile of EPA + DHA dietary intake become linked to greater hippocampal volume in models minimally adjusted for age and sex.28 because the consumption of EPA + DHA is totally correlated with RBC tiers,29,30 this discovering would be per ours. greater recently, a randomized managed trial (2.2 g/d of EPA + DHA vs placebo for six months) in sixty five guys and girls (usual age sixty four years) detected increased quantity in the hippocampus, and the full grey count number declined handiest within the placebo neighborhood.e2

A fresh dose-response examine discovered that one year of 0.93 and 1.86 g/d of EPA + DHA accelerated RBC ranges by means of three.6% and 4.5%, respectively.31 hence, adjustments in the omega-three index that may also be done via food regimen amendment and/or supplementation are corresponding to those associated with 1 to 2 years of commonplace, age-related brain atrophy.

The basic findings of this study were that total typical (nonischemic) mind and hippocampal volumes were without delay linked to RBC EPA + DHA levels, the omega-3 index. along with the findings of others, their look at suggests that an improved tissue reserve of omega-3 FAs may also slow the lack of cognitive feature or disease that can accompany brain atrophy. despite the fact the omega-3 index become no longer concerning cognitive domains in WHISCA (girls's fitness Initiative study of Cognitive getting old),32 a analyze is currently below method to investigate the relations between it and clinically adjudicated in all likelihood dementia in WHIMS. Animal and human stories have established that DHA deficiency throughout the prenatal duration effects in cognitive or behavioral deficits, and that these alterations reverse with omega-3 supplementation.33 It has been shown that DHA supplementation promotes neuron growth in hippocampus cells in vitro and in rat models.34 average mind features reminiscent of synaptic plasticity and neurotransmission continue to be dependent on ample DHA consumption all through the lifespan.35 notwithstanding DHA has a role in brain development, the function of dietary DHA in retaining general mind function is still controversial. DHA mind metabolism was studied in 14 fit grownup men and women between 19 and sixty four years of age using radiolabeled DHA and PET.36 The web rate of human mind DHA uptake changed into three.8 ± 1.7 mg/d, which implied a 2.5-yr half-lifestyles assuming 5 g of total DHA within the mind. To the extent that incorporation of DHA into neuronal membranes is crucial in keeping cognitive characteristic, future supplementation reviews may need to be a few years lengthy.

EPA + DHA are very inefficiently (i.e., <5%) created from the plant essential omega-3 FA α-linolenic acid and are as a consequence gold standard bought preformed within the diet. In about three,200 Framingham Offspring topics, a combination of EPA + DHA intake and using fish oil supplements defined forty% of the whole variability in the omega-three index; an extra 25% was as a result of heritability.30 The heritability aspect reflects the metabolic efficiency with which dietary omega-three FAs are absorbed and integrated into RBC membranes, and as such the omega-3 index is a postmetabolism biomarker used in area of dietary intake.

In previous reviews, omega-three FA quantities had been pronounced in loads of ways: as weight %, mol %, or attention (through volume or cellphone count number), and in many kinds of blood/tissue. The leading debate is the reporting of relative vs absolute amounts, whereas the different tissue kinds can represent different durations of publicity.37 Absolute concentrations upward push and fall with total lipoprotein levels because the majority of lipids they lift contain FAs, whereas the usage of relative %, certainly for membranes akin to RBCs, more totally reflects the composition (and hence characteristic) of other mobile membranes. In a population, plasma % and RBC % are strongly correlated31; despite the fact, omega-three RBC % has the skills of lower inside-adult variability than plasma %, and resistance to a single significant dose of fish oil.38,39

youngsters the omega-3 index changed into measured best once eight years earlier than the MRI scan, it is going to be stable in subjects who didn't alter/initiate fish oil supplementation. This was proven in 250 Framingham Offspring participants with levels measured 7 years aside.40 additionally in that analyze, the percentage of members who begun taking fish oil supplements accelerated from 3% round 1999 to 13% in 2006. These dates overlap nicely with the current examine whereby the WHI screening consult with blood draw and MRI scan dates were around 1998 and 2006, respectively. This means that approximately 10% of the WHIMS subjects may additionally have begun taking fish oil supplements after the screening visit, although this variable changed into now not captured in the trial. if so, this is able to have probably preserved some brain volume, which might cause the mentioned associations to be underestimated.

in this cohort of postmenopausal women, reduce RBC EPA + DHA ranges correlated with smaller total and hippocampal brain volumes, the previous being an indication of cognitive getting older and the latter being centrally concerned with advert pathology. This examine hence provides to the turning out to be literature suggesting that larger omega-three FA tissue levels, which can be executed by dietary alterations, may additionally cling promise for delaying cognitive growing older and/or dementia.

glossary advert Alzheimer disease CRP C-reactive protein DHA docosahexaenoic acid EPA eicosapentaenoic acid FA fatty acid HDL excessive-density lipoprotein HT hormone remedyQ1 first quartile q4 fourth quartile RBC pink blood cellular phoneWHI girls's health Initiative WHIMS girls's fitness Initiative memory analyze author CONTRIBUTIONS

Dr. Pottala drafted and edited the manuscript, analyzed the statistics, interpreted the findings, and designed the study. Dr. Yaffe reviewed and edited the manuscript, and interpreted the findings. Dr. Robinson and Dr. Espeland reviewed and edited the manuscript, interpreted the findings, and designed the study. Dr. Wallace reviewed and edited the manuscript, and interpreted the findings. Dr. Harris reviewed and edited the manuscript, accumulated the RBC fatty acid facts, interpreted the findings, and designed the study.

analyze FUNDING

Supported in part under a contract with the country wide heart, Lung, and Blood Institute (BAA 19). The WHI software is funded by using the national coronary heart, Lung, and Blood Institute, NIH, US branch of health and Human capabilities, through contracts HSN268201100046C;, HHSN268201100001C;, HHSN268201100002C;, HSN268201100003C;, HHSN268201100004C;, and HHSN271201100004C.


J. Pottala stories no disclosures. ok. Yaffe serves on the WHI scientific advisory board, the brain center clinical Advisory Board, and the DSMB for NIA and Takeda; she is also a specialist for Lilly and Novartis. J. Robinson has served as main investigator for provides acquired via the tuition of Iowa from Amarin, Amgen, Daiichi-Sankyo, Genentech/Hoffmann La Roche, and GlaxoSmithKline. M. Espeland serves on statistics and safety Monitoring Boards for the KOWA analysis Institute and the Terumo clinical corporation, and a steering Committee for Boehringer-Ingelheim pharmaceuticals. R. Wallace studies no disclosures. W. Harris owns OmegaQuant Analytics, LLC, and is a Senior research Scientist at fitness Diagnostic Laboratory, Inc., each of which offer pink blood mobile fatty acid checks. he is additionally a scientific guide to Omthera prescribed drugs and Aker BioMarine Antarctic. Go to Neurology.org for full disclosures.

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