Medicine
®
OBSERVATIONAL STUDY
The Associations Between Helicobacter pylori Infection, Serum Vitamin D, and Metabolic Syndrome A Community-Based Study Li-Wei Chen, MD, Chih-Yi Chien, PhD, Chia-Wen Hsieh, BA, Liang-Che Chang, MD, Mei-Huei Huang, MT, Wen-Yuan Huang, MT, Sheng-Fong Kuo, MD, Cheng-Hung Chien, MD, Chih-Lang Lin, PhD, and Rong-Nan Chien, MD
Abstract: The associations between Helicobacter pylori infection, serum vitamin D level, and metabolic syndrome (MS) are controversial. The present community-based study aimed to investigate the effect of H pylori infection and serum vitamin D deficiency on MS development. Individuals from the northeastern region of Taiwan were enrolled in a community-based study from March, 2014 to August, 2015. All participants completed a demographic survey and underwent the urea breath test (UBT) to detect H pylori infection as well as blood tests to determine levels of vitamin D, adiponectin, leptin, and high-sensitivity C-reactive protein. The ATP III criteria for MS were used in this study. A total of 792 men and 1321 women were enrolled. The mean age was 56.4 13.0 years. After adjusting for age and sex, the estimated odds of MS development for a UBT-positive subject were 1.503 (95% confidence interval [CI]: 1.206–1.872, P < 0.001) when compared to a UBT-negative subject. For participants with vitamin D deficiency (30 ng/mL). For participants with both H pylori infection and vitamin D deficiency, the odds of MS development were 2.140 (95% CI: 1.348–3.398, P ¼ 0.001) when compared to subjects without H pylori infection and with sufficient vitamin D levels. H pylori infection and vitamin D deficiency could be predictors of MS. For individuals with both H pylori infection and vitamin D deficiency, the odds of MS development were 2.140 when compared to individuals without H pylori infection and with sufficient vitamin D levels.
Editor: Natale Figura. Received: January 9, 2016; revised: April 6, 2016; accepted: April 13, 2016. From the Department of Gastroenterology and Hepatology (L-WC, C-HC, C-LL, R-NC), Chang-Gung Memorial Hospital and University, Keelung, Taiwan; Community Medicine Research Center (L-WC, C-YC, CWH, SFK, C-HC, C-LL, R-NC), Chang-Gung Memorial Hospital and University, Keelung, Taiwan; Department of Laboratory Medicine and Anatomic Pathology (L-CC, M-HH, W-YH), Chang-Gung Memorial Hospital and University, Keelung, Taiwan; and Metabolism and Endocrinology (S-FK), Chang-Gung Memorial Hospital and University, Keelung, Taiwan. Correspondence: Rong-Nan Chien, Department of Gastroenterology and Hepatology, Chang-Gung Memorial Hospital and University, 12F, No 222, Mai-Jin Road, Keelung 20401, Taiwan (e-mail: [email protected]). This study was supported by grants from Chang-Gung Memorial Hospital (No CMRPG2B0123 and CMRPG2B0173). The authors report no conflicts of interest to disclose. Copyright # 2016 Wolters Kluwer Health, Inc. All rights reserved. This is an open access article distributed under the Creative Commons Attribution License 4.0, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ISSN: 0025-7974 DOI: 10.1097/MD.0000000000003616
Medicine
Volume 95, Number 18, May 2016
(Medicine 95(18):e3616) Abbreviations: CI = confidence interval, DM = diabetes mellitus, HDL-C = high-density lipoprotein cholesterol, HOMA-IR = homeostasis model assessment of insulin resistance, HS-CRP = high-sensitivity C-reactive protein, IR = insulin resistance, MS = metabolic syndrome, TG = triglycerides, UBT = urea breath test, UVB = ultraviolet B.
INTRODUCTION
H
elicobacter pylori (H pylori) infection may cause chronic gastritis, resulting in chronic inflammation and immune responses.1–3 The inflammatory reactions, which involve many cytokines, including inflammatory cytokines and adipokines,4–9 were reported to be associated with insulin resistance (IR) and metabolic syndrome (MS).10–14 The relationship between serum vitamin D and MS development has been a matter of debate.15–19 According to an Italian study, patients with H pylori infection-related gastritis had lower serum vitamin D concentrations.20 Other studies also revealed that vitamin D deficiency could be a predisposing factor for autoimmune gastritis and gastric cancer.21– 24 We hypothesized that H pylori infection and vitamin D deficiency might induce local or systemic inflammatory response via an inflammatory cytokine (high-sensitivity C-reactive protein [HS-CRP]) or adipokines (adiponectin, leptin), leading to the development of IR and MS. Therefore, this community cohort study aimed to analyze the association between H pylori infection and serum vitamin D. The influences of H pylori infection and serum vitamin D level on MS development were also investigated.
MATERIALS AND METHODS This community-based study was performed from March, 2014 to August, 2015 in the northeastern region of Taiwan. The inclusion criteria were age >30 years and absence of pregnancy. Individuals who had received vitamin D supplementation, proton pump inhibitors, H pylori eradication therapy, or antibiotics potentially influencing the results of serum vitamin D measurements or H pylori detection tests within the 3 previous months were excluded. We also excluded patients with possible H pylorirelated extra-digestive diseases, such as osteoporosis, obesity, autoimmune thyroiditis, lupus, refractory anemia, and idiopathic thrombocytopenia, because these diseases might interfere with MS analysis. All participants completed a demographic survey and underwent a physical examination, urea breath test (UBT) for detecting H pylori infection, and blood tests. The demographic survey assessed the past history of systemic diseases, such as diabetes mellitus (DM), hypertension, hyperlipidemia, www.md-journal.com |
1
Medicine
Chen et al
hematologic disorders, and autoimmune diseases, medication history, including ongoing vitamin D supplementation, proton pump inhibitor therapy, H pylori eradication, and antibiotics received within the 3 previous months, and family history. The physical examination included the measurement of heart rate, blood pressure, body weight, body height, and waist girth (circumference). Body mass index (kg/m2) was calculated as weight (kg) divided by squared height (m). Waist girth was measured at the midline between the lowest margin of the subcostal rib and the upper margin of the iliac crest. Blood samples were obtained after an overnight fast, and the following parameters were determined: complete blood cell count, liver and renal biochemistry parameters, lipid profiles, fasting sugar and insulin levels, total vitamin D level, and levels of adiponectin, leptin, and HS-CRP. Blood samples were analyzed within 4 hours after collection to determine complete blood cell counts, biochemical parameters, and antibody titers. The assays for adiponectin and leptin were performed using stored serum samples. The serum samples were stored in tubes at 80 8C following centrifugation (3000 rpm at 4 8C for 30 minutes). The Institutional Review Board of the Chang-Gung Memorial Hospital approved this research (IRB No: 103-3886C). All participants agreed to study conditions and signed the informed consent form before the enrollment in this study.
Urea Breath Test 13 C-UBT was performed after an overnight fast using the Proto Pylori kit (Isodiagnostika, Canada) containing 75 mg of 13 C-urea and additives. Two breath samples obtained within a 30-minute interval were analyzed by gas chromatography/isotope ratio mass spectrometry. Results were expressed as delta over baseline (DOB). A local validation test with a DOB cut-off value of 3.5 yielded a sensitivity of 96% (95% confidence interval [CI]: 93%–99%) and a specificity of 98% (95% CI: 93%–102%) relative to the manufacturer’s reference.
Serum Vitamin D Serum concentrations of vitamin D (25-hydroxyvitamin D [25(OH)D]) were measured using a radioimmunoassay (Vitamin D total, Roche Diagnostics, Mannheim, German) according to the manufacturer’s instructions. The electrochemiluminescence binding assay was performed using Elecsys and Cobas immunoassay analyzers, with the measurement ranges of 3.00 to 70.0 ng/mL and 7.50 to 175 nmol/L. Vitamin D status was defined based on the traditional classification as ‘‘deficient’’ (30 ng/mL, level 3).25
Adiponectin and Leptin Levels Levels of adiponectin and leptin were evaluated using commercial kits (Human Total Adiponectin/Acrp30, BioVendor Research and Diagnostic system, Minneapolis, MN; Human Leptin ELISA, Clinical Range, BioVendor Laboratory Medicine, Karasek, Czech Republic) according to the manufacturers’ instructions. The method of analysis was the quantitative sandwich enzyme immunoassay.
Homeostasis Model Assessment of Insulin Resistance (HOMA-IR) Since IR is one of the key mechanisms for MS development, we assessed IR using the homeostatic model assessment (HOMA-IR) score.26 The HOMA-IR score was calculated by the following formula:
2
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Volume 95, Number 18, May 2016
Fasting plasma insulin (mU/L) fasting plasma glucose (mmol/L)/22.5 A higher HOMA-IR score corresponds to lower insulin sensitivity.27
Metabolic Syndrome A race-specific waist girth threshold based on the NCEP ATP III criteria28–30 was utilized to prevent distortions in MS prevalence. The cut-off values for normal waist circumference in Asian men and women were set to 90 cm (35 inches) and 80 cm (31.5 inches), respectively. MS was defined according to the ATP III criteria as the presence of at least three of the following five traits: visceral (abdominal) obesity, determined on the basis of the Asian waist circumference cut-offs (men: >90 cm, women: >80 cm); blood pressure 130/85 mm Hg or drug treatment for essential hypertension; serum high-density lipoprotein cholesterol (HDL-C) level
®
OBSERVATIONAL STUDY
The Associations Between Helicobacter pylori Infection, Serum Vitamin D, and Metabolic Syndrome A Community-Based Study Li-Wei Chen, MD, Chih-Yi Chien, PhD, Chia-Wen Hsieh, BA, Liang-Che Chang, MD, Mei-Huei Huang, MT, Wen-Yuan Huang, MT, Sheng-Fong Kuo, MD, Cheng-Hung Chien, MD, Chih-Lang Lin, PhD, and Rong-Nan Chien, MD
Abstract: The associations between Helicobacter pylori infection, serum vitamin D level, and metabolic syndrome (MS) are controversial. The present community-based study aimed to investigate the effect of H pylori infection and serum vitamin D deficiency on MS development. Individuals from the northeastern region of Taiwan were enrolled in a community-based study from March, 2014 to August, 2015. All participants completed a demographic survey and underwent the urea breath test (UBT) to detect H pylori infection as well as blood tests to determine levels of vitamin D, adiponectin, leptin, and high-sensitivity C-reactive protein. The ATP III criteria for MS were used in this study. A total of 792 men and 1321 women were enrolled. The mean age was 56.4 13.0 years. After adjusting for age and sex, the estimated odds of MS development for a UBT-positive subject were 1.503 (95% confidence interval [CI]: 1.206–1.872, P < 0.001) when compared to a UBT-negative subject. For participants with vitamin D deficiency (30 ng/mL). For participants with both H pylori infection and vitamin D deficiency, the odds of MS development were 2.140 (95% CI: 1.348–3.398, P ¼ 0.001) when compared to subjects without H pylori infection and with sufficient vitamin D levels. H pylori infection and vitamin D deficiency could be predictors of MS. For individuals with both H pylori infection and vitamin D deficiency, the odds of MS development were 2.140 when compared to individuals without H pylori infection and with sufficient vitamin D levels.
Editor: Natale Figura. Received: January 9, 2016; revised: April 6, 2016; accepted: April 13, 2016. From the Department of Gastroenterology and Hepatology (L-WC, C-HC, C-LL, R-NC), Chang-Gung Memorial Hospital and University, Keelung, Taiwan; Community Medicine Research Center (L-WC, C-YC, CWH, SFK, C-HC, C-LL, R-NC), Chang-Gung Memorial Hospital and University, Keelung, Taiwan; Department of Laboratory Medicine and Anatomic Pathology (L-CC, M-HH, W-YH), Chang-Gung Memorial Hospital and University, Keelung, Taiwan; and Metabolism and Endocrinology (S-FK), Chang-Gung Memorial Hospital and University, Keelung, Taiwan. Correspondence: Rong-Nan Chien, Department of Gastroenterology and Hepatology, Chang-Gung Memorial Hospital and University, 12F, No 222, Mai-Jin Road, Keelung 20401, Taiwan (e-mail: [email protected]). This study was supported by grants from Chang-Gung Memorial Hospital (No CMRPG2B0123 and CMRPG2B0173). The authors report no conflicts of interest to disclose. Copyright # 2016 Wolters Kluwer Health, Inc. All rights reserved. This is an open access article distributed under the Creative Commons Attribution License 4.0, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ISSN: 0025-7974 DOI: 10.1097/MD.0000000000003616
Medicine
Volume 95, Number 18, May 2016
(Medicine 95(18):e3616) Abbreviations: CI = confidence interval, DM = diabetes mellitus, HDL-C = high-density lipoprotein cholesterol, HOMA-IR = homeostasis model assessment of insulin resistance, HS-CRP = high-sensitivity C-reactive protein, IR = insulin resistance, MS = metabolic syndrome, TG = triglycerides, UBT = urea breath test, UVB = ultraviolet B.
INTRODUCTION
H
elicobacter pylori (H pylori) infection may cause chronic gastritis, resulting in chronic inflammation and immune responses.1–3 The inflammatory reactions, which involve many cytokines, including inflammatory cytokines and adipokines,4–9 were reported to be associated with insulin resistance (IR) and metabolic syndrome (MS).10–14 The relationship between serum vitamin D and MS development has been a matter of debate.15–19 According to an Italian study, patients with H pylori infection-related gastritis had lower serum vitamin D concentrations.20 Other studies also revealed that vitamin D deficiency could be a predisposing factor for autoimmune gastritis and gastric cancer.21– 24 We hypothesized that H pylori infection and vitamin D deficiency might induce local or systemic inflammatory response via an inflammatory cytokine (high-sensitivity C-reactive protein [HS-CRP]) or adipokines (adiponectin, leptin), leading to the development of IR and MS. Therefore, this community cohort study aimed to analyze the association between H pylori infection and serum vitamin D. The influences of H pylori infection and serum vitamin D level on MS development were also investigated.
MATERIALS AND METHODS This community-based study was performed from March, 2014 to August, 2015 in the northeastern region of Taiwan. The inclusion criteria were age >30 years and absence of pregnancy. Individuals who had received vitamin D supplementation, proton pump inhibitors, H pylori eradication therapy, or antibiotics potentially influencing the results of serum vitamin D measurements or H pylori detection tests within the 3 previous months were excluded. We also excluded patients with possible H pylorirelated extra-digestive diseases, such as osteoporosis, obesity, autoimmune thyroiditis, lupus, refractory anemia, and idiopathic thrombocytopenia, because these diseases might interfere with MS analysis. All participants completed a demographic survey and underwent a physical examination, urea breath test (UBT) for detecting H pylori infection, and blood tests. The demographic survey assessed the past history of systemic diseases, such as diabetes mellitus (DM), hypertension, hyperlipidemia, www.md-journal.com |
1
Medicine
Chen et al
hematologic disorders, and autoimmune diseases, medication history, including ongoing vitamin D supplementation, proton pump inhibitor therapy, H pylori eradication, and antibiotics received within the 3 previous months, and family history. The physical examination included the measurement of heart rate, blood pressure, body weight, body height, and waist girth (circumference). Body mass index (kg/m2) was calculated as weight (kg) divided by squared height (m). Waist girth was measured at the midline between the lowest margin of the subcostal rib and the upper margin of the iliac crest. Blood samples were obtained after an overnight fast, and the following parameters were determined: complete blood cell count, liver and renal biochemistry parameters, lipid profiles, fasting sugar and insulin levels, total vitamin D level, and levels of adiponectin, leptin, and HS-CRP. Blood samples were analyzed within 4 hours after collection to determine complete blood cell counts, biochemical parameters, and antibody titers. The assays for adiponectin and leptin were performed using stored serum samples. The serum samples were stored in tubes at 80 8C following centrifugation (3000 rpm at 4 8C for 30 minutes). The Institutional Review Board of the Chang-Gung Memorial Hospital approved this research (IRB No: 103-3886C). All participants agreed to study conditions and signed the informed consent form before the enrollment in this study.
Urea Breath Test 13 C-UBT was performed after an overnight fast using the Proto Pylori kit (Isodiagnostika, Canada) containing 75 mg of 13 C-urea and additives. Two breath samples obtained within a 30-minute interval were analyzed by gas chromatography/isotope ratio mass spectrometry. Results were expressed as delta over baseline (DOB). A local validation test with a DOB cut-off value of 3.5 yielded a sensitivity of 96% (95% confidence interval [CI]: 93%–99%) and a specificity of 98% (95% CI: 93%–102%) relative to the manufacturer’s reference.
Serum Vitamin D Serum concentrations of vitamin D (25-hydroxyvitamin D [25(OH)D]) were measured using a radioimmunoassay (Vitamin D total, Roche Diagnostics, Mannheim, German) according to the manufacturer’s instructions. The electrochemiluminescence binding assay was performed using Elecsys and Cobas immunoassay analyzers, with the measurement ranges of 3.00 to 70.0 ng/mL and 7.50 to 175 nmol/L. Vitamin D status was defined based on the traditional classification as ‘‘deficient’’ (30 ng/mL, level 3).25
Adiponectin and Leptin Levels Levels of adiponectin and leptin were evaluated using commercial kits (Human Total Adiponectin/Acrp30, BioVendor Research and Diagnostic system, Minneapolis, MN; Human Leptin ELISA, Clinical Range, BioVendor Laboratory Medicine, Karasek, Czech Republic) according to the manufacturers’ instructions. The method of analysis was the quantitative sandwich enzyme immunoassay.
Homeostasis Model Assessment of Insulin Resistance (HOMA-IR) Since IR is one of the key mechanisms for MS development, we assessed IR using the homeostatic model assessment (HOMA-IR) score.26 The HOMA-IR score was calculated by the following formula:
2
| www.md-journal.com
Volume 95, Number 18, May 2016
Fasting plasma insulin (mU/L) fasting plasma glucose (mmol/L)/22.5 A higher HOMA-IR score corresponds to lower insulin sensitivity.27
Metabolic Syndrome A race-specific waist girth threshold based on the NCEP ATP III criteria28–30 was utilized to prevent distortions in MS prevalence. The cut-off values for normal waist circumference in Asian men and women were set to 90 cm (35 inches) and 80 cm (31.5 inches), respectively. MS was defined according to the ATP III criteria as the presence of at least three of the following five traits: visceral (abdominal) obesity, determined on the basis of the Asian waist circumference cut-offs (men: >90 cm, women: >80 cm); blood pressure 130/85 mm Hg or drug treatment for essential hypertension; serum high-density lipoprotein cholesterol (HDL-C) level
