An investigation of the association between lipoxin A4 levels and metabolic syndrome parameters in patients with metabolic syndrome

2021 ◽  
pp. 105-109
Keyword(s):  
Blood Pressure ◽  
Metabolic Syndrome ◽  
Waist Circumference ◽  
Density Lipoprotein ◽  
Public Health Problem ◽  
Serum Levels ◽  
Enzyme Linked Immunosorbent Assay ◽  
Lipoxin A4 ◽  
Male Patients ◽  
Age And Sex

Aim: Metabolic syndrome (MS) is a significant public health problem and has the potential to increase the risk of developing cardiovascular diseases (CVD), the risk of type 2 Diabetes Mellitus (T2DM), the risk of stroke and the risk of a heart attack. MS has recently been considered an inflammatory disease. Lipoxins (LXs) are, on the other hand, bioactive lipid molecules synthesized from arachidonic acid (AA) and show potent anti-inflammatory and pro-resolving activities in vivo and in vitro conditions. In this study, we aimed to evaluate serum levels of LXA4 in MS patients and explore the relationship of serum LXA4 levels with MS components [waist circumference, blood pressure, serum high-density lipoprotein (HDL), and triglyceride (TG) levels]. Material and Method: In this study, the sample was composed of 39 patients diagnosed with MS and 32 healthy age- and sex-matched individuals. We measured serum LXA4 levels adopting the enzyme-linked immunosorbent assay (ELISA) method with “Human Lipoxin A4 ELISA Kit”. While collecting the blood samples from the subjects, we noted their ages, sex, physical examination findings, and anthropometric measurements [height, weight, waist circumference, and body mass index (BMI)]. Additionally, we obtained their serum TG, low-density lipoprotein (LDL), HDL, glucose, and cholesterol levels. Results: While we could not find any significant differences between the groups by age and sex (p>0.05), the groups significantly differed by weight, waist circumference, BMI, systolic blood pressure, diastolic blood pressure, TG, HDL, and FBG (p<0.05 for TG; p<0.001 for others). Moreover, serum levels of LXA4 significantly differed between the groups (p<0.05). Within-group comparisons showed that while serum levels of LXA4 significantly differed between male subjects (p=0.01), it was not the case for females (p>0.05). In both groups, there were negative correlations between serum LXA4 levels and waist circumference (r=-0.368 p=0.02). Yet, we found such an association only among male patients (r=-0.516 p=0.02). Conclusion: Overall, we found serum LXA4 levels to be significantly low in MS patients (p<0.05). Yet, it still needs to be elucidated whether this impairment is a cause or a result of MS. Finally, we discovered this impairment and its significant correlations with some MS parameters to be only in male patients, suggesting that serum LXA4 levels may vary by sex in MS patients.

scholarly journals The role of postprandial very-low-density lipoprotein in the development of atrial remodeling in metabolic syndrome

2020 ◽  
Vol 19 (1) ◽  
Author(s):  
Hsiang-Chun Lee ◽  
Shyi-Jang Shin ◽  
Jih-Kai Huang ◽  
Ming-Yen Lin ◽  
Yu-Hsun Lin ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Blood Pressure ◽  
Metabolic Syndrome ◽  
Waist Circumference ◽  
Low Density Lipoprotein ◽  
Density Lipoprotein ◽  
Atrial Remodeling ◽  
Very Low Density Lipoprotein ◽  
Low Density ◽  
Hip Circumference

Abstract Background Negatively charged very-low-density lipoprotein (VLDL-χ) in metabolic syndrome (MetS) patients exerts cytotoxic effects on endothelial cells and atrial myocytes. Atrial cardiomyopathy, manifested by atrial remodeling with a dilated diameter, contributes to atrial fibrillation pathogenesis and predicts atrial fibrillation development. The correlation of VLDL-χ with atrial remodeling is unknown. This study investigated the association between VLDL-χ and remodeling of left atrium. Methods Consecutively, 87 MetS and 80 non-MetS individuals between 23 and 74 years old (50.6% men) without overt cardiovascular diseases were included in the prospective cohort study. Blood samples were collected while fasting and postprandially (at 0.5, 1, 2, and 4 h after a unified meal). VLDL was isolated by ultracentrifugation; the percentile concentration of VLDL-χ (%) was determined by ultra-performance liquid chromatography. The correlations of left atrium diameter (LAD) with variables including VLDL-χ, LDL-C, HDL-C, triglycerides, glucose, and blood pressure, were analyzed by multiple linear regression models. A hierarchical linear model was conducted to test the independencies of each variable’s correlation with LAD. Results The mean LAD was 3.4 ± 0.5 cm in non-MetS subjects and 3.9 ± 0.5 cm in MetS patients (P < 0.01). None of the fasting lipid profiles were associated with LAD. VLDL-χ, BMI, waist circumference, hip circumference, and blood pressure were positively correlated with LAD (all P < 0.05) after adjustment for age and sex. Significant interactions between VLDL-χ and blood pressure, waist circumference, and hip circumference were observed. When adjusted for obesity- and blood pressure-related variables, 2-h postprandial VLDL-χ (mean 1.30 ± 0.61%) showed a positive correlation with LAD in MetS patients. Each 1% VLDL-χ increase was estimated to increase LAD by 0.23 cm. Conclusions Postprandial VLDL-χ is associated with atrial remodeling particularly in the MetS group. VLDL-χ is a novel biomarker and may be a therapeutic target for atrial cardiomyopathy in MetS patients. Trial registration ISRCTN 69295295. Retrospectively registered 9 June 2020.

Down-regulation of S100A1 protein in patients with metabolic syndrome and its association with zinc-α2-glycoprotein

2017 ◽  
Vol 62 (3) ◽  
pp. 88-95 ◽  
Author(s):  
Elham Ebrahimi ◽  
Sorayya Kheirouri ◽  
Mohammad Alizadeh
Keyword(s):  
Blood Pressure ◽  
Metabolic Syndrome ◽  
Multiple Testing ◽  
Density Lipoprotein ◽  
Serum Zinc ◽  
Serum Levels ◽  
Control Group ◽  
Strong Positive Correlation ◽  
The Metabolic Syndrome ◽  
Equivalent Number

Objectives It has been proposed that zinc-α2-glycoprotein and S100A1 are possibly linked to the development of lipogenesis and obesity. We aimed to measure serum levels of S100A1 and zinc-α2-glycoprotein in patients with metabolic syndrome and investigate any associations of these two novel peptides with each other or components of metabolic syndrome. Methods Forty-four patients with metabolic syndrome and the equivalent number of healthy controls participated in this study. The participants’ body mass index, waist circumference, systolic and diastolic blood pressure were measured. Serum levels of low- and high-density lipoprotein cholesterol, total cholesterol, triglyceride, fasting blood sugar, insulin, zinc-α2-glycoprotein and S100A1 protein were determined. Results Higher levels of anthropometric and lipid indices, metabolic factors and also SBP and DBP were observed in the metabolic syndrome group. Serum S100A1 levels were significantly lower in the metabolic syndrome group than the control group ( P = 0.008). There was a strong positive correlation between serum zinc-α2-glycoprotein and S100A1 levels ( r = 0.80, P < 0.0001). Serum levels of both S100A1 ( P = 0.03) and zinc-α2-glycoprotein ( P = 0.02) were potentially higher in subjects with hypertension than those with normal blood pressure, though these were found as part of multiple testing. Conclusion The results indicate that changes in the circulating level of S100A1 protein occur in metabolic syndrome patients. The strong correlation between serum zinc-α2-glycoprotein and S100A1 might suggest that production or release of these two proteins could be related mechanistically.

Abstract P111: A Cluster Randomized Controlled Trial to Examine the Effects of Tai Chi and Walking Exercises on Weight Loss, Metabolic Syndrome Parameters, and Bone Mineral Density

Circulation ◽  
2015 ◽  
Vol 131 (suppl_1) ◽  
Author(s):  
Yao Jie Xie ◽  
Stanley Sai-chuen Hui ◽  
Timothy Chi-yui Kwok ◽  
Jean Woo
Keyword(s):  
Bone Mineral Density ◽  
Blood Pressure ◽  
Metabolic Syndrome ◽  
Weight Loss ◽  
Body Weight ◽  
Waist Circumference ◽  
Lean Mass ◽  
Tai Chi ◽  
Density Lipoprotein ◽  
Mineral Density

Introduction: Tai Chi and walking are both moderate-intensity physical activity (PA) that can be easily practiced in daily life. The purpose of this study was to better understand that after practicing these two types of PAs in a relative short term and keeping the stable dietary intake in this period, how much body weight would be reduced and what extent the metabolic syndrome parameters would be improved; and if a significant weight loss was observed, whether this exercise-induced weight loss had adverse effect on bone mineral density (BMD). Methods: Three-hundred seventy-four healthy and physically inactive adults (45.8±5.3 years) from 9 geographic areas in Hong Kong were randomized to 12 weeks training (45 minutes per day, 5 days per week) of Tai Chi (n=124) or self-paced walking (n=121), or control group (n=129) at area level. Body weight, fat and lean mass, waist circumference, blood pressure and regional BMD, as well as the fasting blood samples were obtained at the beginning and end of trial. Fasting blood glucose (FBG), total cholesterol, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C) and triglycerides were analyzed. Results: On average, Tai Chi and walking groups lost 0.50 and 0.76 kg of body weight, 0.47 and 0.59 kg of fat mass, respectively (all p<0.001). No significant changes were observed for lean mass and BMD. Two intervention groups had significant improvements in waist circumference and FBG. The between-group difference of waist circumference and FBG was -3.7 cm and -0.18 mmol/L for Tai Chi vs. control; and -4.1 cm and -0.22 mmol/L for walking vs. control (all p<0.001). No significant differences were observed regarding blood pressure, total cholesterol, HDL-C, LDL-C and triglycerides compared to control (all p>0.05). The effects on all outcomes between Tai Chi and walking were similar (all p>0.05). Among intervention groups, change in lean mass, not fat mass or total weight loss, was significantly correlated to the change in BMD. Conclusions: 12-week Tai Chi and walking exercises can produce moderate weight loss and improve the waist circumference and FBG in middle-aged Hong Kong Chinese people, with no additional effects on BMD.

scholarly journals Action Mechanism of Rosella (Hibiscus sabdariffa L.) Used to Treat Metabolic Syndrome in Elderly Women

2020 ◽  
Vol 2020 ◽  
pp. 1-6
Author(s):  
Yusni Yusni ◽  
Firdalena Meutia
Keyword(s):  
Blood Pressure ◽  
Metabolic Syndrome ◽  
Elderly Women ◽  
Density Lipoprotein ◽  
The Elderly ◽  
Elderly Subjects ◽  
Enzyme Linked Immunosorbent Assay ◽  
Control Group ◽  
Control Group Design ◽  
Cortisol Levels

Objective. Rosella is a safe medicinal herb used by people in Indonesia. They believe that rosella is effective in controlling metabolic syndrome, working with antihypertension, antidiabetic, antidyslipidemia and antiobesity effects. The purpose of this study was to determine the effect of rosella in controlling metabolic syndrome through the secretion of blood nitric oxide (NO) and the cortisol pathway. Methods. This study was a quasiexperimental, pretest-posttest with control group design. The total subjects were 18 people, women, and the elderly. Subjects were selected randomly into 2 groups: control group (n = 8) and treatment group (n = 8). The treatment was rosella tea, a dose of 2 grams, duration 2 times a day, given in the morning (08.00–8.30 a.m.) and evening (06.30–7.00 p.m.) after meals for 21 days. Examination of NO and cortisol levels was carried out using the enzyme-linked immunosorbent assay (ELISA) method. Results. There was a significant decrease in bodyweight (BW) (p=0.021), systolic blood pressure (SBP) (p=0.001), diastolic blood pressure (DBP) (p=0.049), glucose preprandial (FPG) (p=0.014), total cholesterol (CT) (p=0.001), triglycerides (TGs) (p=0.014), high-density lipoprotein (HDL) (p=0.001), and low-density lipoprotein (LDL) (p=0.010) after consuming rosella. NO levels were significantly increased (p=0.012), whereas cortisol levels decreased significantly (p=0.008) after therapy with rosella tea in elderly women. Conclusion. Rosella has shown evidence to control and lower blood pressure, blood glucose, lipid profile, and cortisol in the elderly with metabolic syndrome. Rosella is a traditional medicine that has the potential to be developed as a therapy for metabolic syndrome patients.

scholarly journals The prevalence of metabolic syndrome in male patients of early onset androgenic alopecia compared to age matched controls

2021 ◽  
Author(s):  
Nitin D. Chaudhari ◽  
Chandrakant B. Poulkar ◽  
Swapna S. Khatu ◽  
Gaurav H. Khandait ◽  
Rajvardhan M. Bagane ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Metabolic Syndrome ◽  
Waist Circumference ◽  
Early Onset ◽  
High Density ◽  
High Density Lipoproteins ◽  
P Value ◽  
Early Screening ◽  
Androgenic Alopecia ◽  
Male Patients

<p class="abstract"><strong>Background:</strong> Androgenic alopecia is most common type of non-scarring alopecia in men. It is associated with high risk of cardiovascular events. Aim was to study the prevalence of metabolic syndrome in male patients of early onset androgenic alopecia.</p><p class="abstract"><strong>Methods:</strong> A case-control study was conducted at the dermatology out-patient department over a period of 6 months which included 100 patients of androgenic alopecia and 100 age matched controls. All subjects were aged 20 to 35 years and underwent detailed history, clinical examination including trichoscopic examination and measurement of waist circumference and blood pressure. Fasting blood sugar, triglyceride and high-density lipoproteins were tested following overnight fasting. Diagnosis of metabolic syndrome was based on criteria of national cholesterol education program (NCEP) adult treatment panel III. Chi square test was used as a test of significance. P value &lt;0.05 was considered statistically significant.<strong></strong></p><p class="abstract"><strong>Results:</strong> Prevalence of metabolic syndrome was more in androgenic alopecia patients than in controls (48% versus 18%, p value &lt;0.001). Androgenic alopecia patients had higher prevalence of increased waist circumference (76% versus 28%, p value &lt;0.0001), increased diastolic blood pressure (32% versus 12%, p value=0.007), increased serum triglycerides (46% versus 24%, p value=0.0011) and decreased serum high-density lipoproteins (36% versus 18%, p value=0.0042) compared to controls.</p><p class="abstract"><strong>Conclusions:</strong> Early screening for metabolic syndrome and its components is beneficial in patients with androgenic alopecia to reduce cardiovascular mortality.</p>

scholarly journals The Role of Postprandial Very-Low-Density Lipoprotein ­in the Development of Atrial Remodeling in Metabolic Syndrome

2020 ◽  
Author(s):  
Hsiang-Chun Lee ◽  
Shyi-Jang Shin ◽  
Jih-Kai Huang ◽  
Ming-Yen Lin ◽  
Yu-Hsun Lin ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Blood Pressure ◽  
Metabolic Syndrome ◽  
Waist Circumference ◽  
Low Density Lipoprotein ◽  
Density Lipoprotein ◽  
Atrial Remodeling ◽  
Very Low Density Lipoprotein ◽  
Low Density ◽  
Linear Regression Models

Abstract Background: Negatively charged very-low-density lipoprotein (VLDL-χ) in metabolic syndrome (MetS) patients exerts cytotoxic effects on endothelial cells and atrial myocytes. Atrial cardiomyopathy, manifested by atrial remodeling with a dilated diameter, contributes to atrial fibrillation pathogenesis and predicts atrial fibrillation development. The correlation of VLDL-χ with atrial remodeling is unknown. This study investigated the association between VLDL-χ and the remodeling of left atrium.Methods: Consecutively, 87 MetS and 80 non-MetS individuals between 23 and 74 years old (50.6% men) without overt cardiovascular diseases were included in the prospective cohort study. Blood samples were collected while fasting and postprandially (at 0.5, 1, 2, and 4 hours after a unified meal). VLDL was isolated by ultracentrifugation; the percentile concentration of VLDL-χ (%) was determined by ultra-performance liquid chromatography. The correlations of left atrial diameter (LAD) with variables including VLDL-χ, LDL-C, HDL-C, triglycerides, glucose, and blood pressure, were analyzed by multiple linear regression models. A hierarchicallinear model was conducted to test the independencies of each variable’s correlation with LAD.Results: The mean LAD was 3.4 ± 0.5 cm in non-MetS subjects and 3.9 ± 0.5 cm in MetS patients (P< 0.01). None of the fasting lipid profiles were associated with LAD. VLDL-χ, BMI, waist circumference, hip circumference, and blood pressure were positively correlated with LAD (all P<0.05) after adjustment for age and sex. Significant interactions between VLDL-χ and blood pressure, waist circumference, and hipcircumference were observed. When adjusted for obesity- and blood pressure-related variables, 2-hour postprandial VLDL-χ (mean 1.30 ± 0.61%) showed a positive correlation with LAD in MetS patients. Each 1% VLDL-χ increase was estimated to increase LAD by 0.23 cm.Conclusions: Postprandial VLDL-χ is associated with atrial remodeling particularly in the MetS group. VLDL-χ is a novel biomarker and may be a therapeutic target for atrial cardiomyopathy in MetS patients.Trial registration: ISRCTN 69295295. Retrospectively registered 9 June 2020.

scholarly journals Incidence of and factors associated with metabolic syndrome, south-east Islamic Republic of Iran

2021 ◽  
Author(s):  
Khadijeh K. Farmanfarma ◽  
Alireza Ansari-Moghaddam ◽  
Mahmoud A. Kaykhaei ◽  
Mehdi Mohammadi ◽  
Hosein A. Adineh ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Cardiovascular Disease ◽  
Metabolic Syndrome ◽  
Waist Circumference ◽  
High Blood Pressure ◽  
Low Density Lipoprotein ◽  
Density Lipoprotein ◽  
Waterpipe Smoking ◽  
Islamic Republic ◽  
Islamic Republic Of Iran

Background: Metabolic syndrome is an important cause of cardiovascular disease. Mortality from cardiovascular disease is 12.82 deaths/100 000 population in Zahedan, south-east Islamic Republic of Iran. Aims: This study aimed to determine the incidence of metabolic syndrome and its predicting factors in Zahedan city. Methods: All participants without metabolic syndrome in a 2009 study in Zahedan, available in 2017, were included in this study. Metabolic syndrome was diagnosed based on the criteria of several organizations. Anthropometric indices and blood pressure were measured and blood tests were done. Age-standardized incidence of metabolic syndrome was calculated and its predictors were evaluated in a logistic regression analysis. Results: Mean age (standard deviation) of the participants was 45.46 (12.63) years in 2017. The incidence of metabolic syndrome varied from 17.21% to 27.18% depending on the criteria used and it was higher in women. High age-standardized incidence was associated with large waist circumference (55.81%) and high blood pressure (25.32%). The highest adjusted odds ratios (OR) for metabolic syndrome were for high triglycerides (OR = 23.75; 95% confidence interval (CI): 9.92–56.84%), large waist circumference (OR = 22.42; 95% CI: 9.03–55.70%), high blood pressure (OR = 16.91; 95% CI: 8.54–33.50%) and high fasting blood sugar (OR = 13.22; 95% CI: 6.74–25.94%). Waterpipe smoking, sex, low-density lipoprotein and wrist circumference were also associated with metabolic syndrome. Conclusions: The incidence of metabolic syndrome has increased in Zahedan. Effective, interventions, including to promote healthy diet, physical activity and avoidance of waterpipe smoking, are needed to control this condition.

scholarly journals Metabolic Syndrome and Periodontitis: Is Oxidative Stress a Common Link?

2009 ◽  
Vol 88 (6) ◽  
pp. 503-518 ◽  
Author(s):  
P. Bullon ◽  
J.M. Morillo ◽  
M.C. Ramirez-Tortosa ◽  
J.L. Quiles ◽  
H.N. Newman ◽  
...  
Keyword(s):  
Oxidative Stress ◽  
Blood Pressure ◽  
Cardiovascular Disease ◽  
Metabolic Syndrome ◽  
Density Lipoprotein ◽  
Serum Levels ◽  
Inflammatory State ◽  
Anti Oxidant ◽  
Obesity Hypertension ◽  
The Relationship

A review of pathological mechanisms that can explain the relationship between periodontitis and cardiovascular disease (CVD) is necessary to improve the management of both conditions. Metabolic syndrome is a combination of obesity, hypertension, impaired glucose tolerance or diabetes, hyperinsulinemia, and dyslipidemia. All these have been examined in recent years in terms of their relationship to periodontitis. Reviewed data indicate an association between some of them (body mass index, high-density lipoprotein-cholesterol [HDL-C], triglycerides, high blood pressure, among others) and periodontitis. Oxidative stress may act as a potential common link to explain relationships between each component of metabolic syndrome and periodontitis. Both conditions show increased serum levels of products derived from oxidative damage, with a pro-inflammatory state likely influencing each other bidirectionally. Adipocytokines might modulate the oxidant/anti-oxidant balance in this relationship.

scholarly journals Predictors of Metabolic Syndrome in Adults and Older Adults from Amazonas, Brazil

2021 ◽  
Vol 18 (3) ◽  
pp. 1303
Author(s):  
Élvio Rúbio Gouveia ◽  
Bruna R. Gouveia ◽  
Adilson Marques ◽  
Miguel Peralta ◽  
Cíntia França ◽  
...  
Keyword(s):  
Public Health ◽  
Blood Pressure ◽  
Older Adults ◽  
Metabolic Syndrome ◽  
Abdominal Obesity ◽  
Density Lipoprotein ◽  
Public Health Problem ◽  
Individual Risk ◽  
Major Public Health Problem ◽  
Cross Sectional

Metabolic syndrome has been considered a factor of vulnerability and a major public health problem because it increases the risk of cardiovascular disease and type 2 diabetes. The present study from Amazonas, Brazil aimed to estimate the prevalence of the individual and general components of metabolic syndrome in adults and older adults and identify the independent predictors of metabolic syndrome. The sample of the present cross-sectional study comprised 942 participants (590 women), with a mean age of 59.8 ± 19.7 (range: 17.5 to 91.8). Blood pressure in men (62.5%), abdominal obesity in women (67.3%), and lower high-density lipoprotein cholesterol (HDL-C) in both (52.2% in men and 65.0% in women) were the most prevalent individual risk factors for metabolic syndrome. Women had a higher prevalence of abdominal obesity (p < 0.001), low HDL-C (p < 0.001), and metabolic syndrome (p < 0.001) than men; however, opposite results were seen in men for blood pressure (p < 0.001). The overall prevalence of metabolic syndrome was 47.5%. Advanced age, being female, having a higher body mass index, and a having lower educational level independently increased the odds of metabolic syndrome. Due to the association of metabolic syndrome with deterioration of health status and increased vulnerability, this study sustains the need for early public health interventions in the Amazonas region.

scholarly journals The Association between Metabolic Syndrome-Related Indicators and Ten-Year Risk of Cardiovascular Disease: An Epidemiologic Assessment

2012 ◽  
Vol 2012 ◽  
pp. 1-7
Author(s):  
Tsan Yang ◽  
Chien-An Sun ◽  
Ching-Chuan Chen ◽  
Szu-Hsien Wu ◽  
Tieh-Chi Chung ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Cardiovascular Disease ◽  
Metabolic Syndrome ◽  
Waist Circumference ◽  
Assessment Tool ◽  
Screening Program ◽  
Density Lipoprotein ◽  
Middle Aged ◽  
Heart Study ◽  
Medium Risk

Objectives. This study explored the association between metabolic syndrome-related indicators and the ten-year risk for cardiovascular disease (CVD) in the middle-aged and elderly population. Methods. Data were collected from residents in Southern Taiwan through a health screening program, carried out from March 2007 to May 2008. The present study used the risk assessment tool of the Framingham Heart Study and adopted ≦10% as low risk, 11~20% as medium risk, and >20% as high risk for CVD. Results. We found that subjects with abdominal obesity and hypertension had significantly higher 10-year risk for CVD than those who had normal waist circumference and blood pressure (OR=2.07 and 24.52, resp.). Subjects with hypertriglyceridemia were 1.86 times more at risk for developing medium risk of CVD than those who had normal triglyceride levels. Furthermore, individuals with reduced high-density lipoprotein cholesterol (HDL-C) had significantly higher 10-year risk for CVD than those who had normal HDL-C. Conclusions. Metabolic syndrome-related indicators were positively associated with 10-year risk for CVD. Waist circumference (WC), blood pressure, triglyceride and HDL-C might be good indicators for predicting the risk of CVD for middle-aged and elderly populations.

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