The effect of warfarin therapy on breast, colorectal, lung, and prostate cancer survival: a population-based cohort study using the Clinical Practice Research Datalink.

PURPOSE: Pre-clinical studies suggest that oral anticoagulant agents, such as warfarin, may inhibit metastases and potentially prolong survival in cancer patients. However, few population-based studies have examined the association between warfarin use and cancer-specific mortality. METHODS: Using prescribing, cause of death, and cancer registration data from the UK Clinical Practice Research Datalink, four population-based cohorts were constructed, comprising breast, colorectal, lung, and prostate cancer patients diagnosed between 1 January 1998, and the 31 December 2010. Comparing pre-diagnostic warfarin users to non-users, multivariable Cox proportional hazard models were used to estimate hazard ratios (HRs) and 95 % confidence intervals (CIs) for cancer-specific mortality. RESULTS: Overall, 16,525 breast, 12,902 colorectal, 12,296 lung, and 12,772 prostate cancers were included. Pre-diagnostic warfarin use ranged from 2.4 to 4.7 %. There was little evidence of any strong association between warfarin use pre-diagnosis and cancer-specific mortality in prostate (adjusted HR 1.03, 95 % CI 0.84-1.26), lung (adjusted HR 1.06, 95 % CI 0.96-1.16), breast (adjusted HR 0.81, 95 % CI 0.62-1.07), or colorectal (adjusted HR 0.88, 95 % CI 0.77-1.01) cancer patients. Dose-response analyses did not reveal consistent evidence of reductions in users of warfarin defined by the number of prescriptions used and daily defined doses. CONCLUSIONS: There was little evidence of associations between pre-diagnostic use of warfarin and cancer-specific mortality in lung, prostate, breast, or colorectal cancer patients.

Beta-blocker usage after malignant melanoma diagnosis and survival: a population-based nested case-control study.

BACKGROUND: Beta-blockers have potential antiangiogenic and antimigratory activity. Studies have demonstrated a survival benefit in patients with malignant melanoma treated with beta-blockers. OBJECTIVES: To investigate the association between postdiagnostic beta-blocker usage and risk of melanoma-specific mortality in a population-based cohort of patients with malignant melanoma. METHODS: Patients with incident malignant melanoma diagnosed between 1998 and 2010 were identified within the U.K. Clinical Practice Research Datalink and confirmed using cancer registry data. Patients with malignant melanoma with a melanoma-specific death (cases) recorded by the Office of National Statistics were matched on year of diagnosis, age and sex to four malignant melanoma controls (who lived at least as long after diagnosis as their matched case). A nested case-control approach was used to investigate the association between postdiagnostic beta-blocker usage and melanoma-specific death and all-cause mortality. Conditional logistic regression was applied to generate odds ratios (ORs) and 95% confidence intervals (CIs) for beta-blocker use determined from general practitioner prescribing. RESULTS: Beta-blocker medications were prescribed after malignant melanoma diagnosis to 20·2% of 242 patients who died from malignant melanoma (cases) and 20·3% of 886 matched controls. Consequently, there was no association between beta-blocker use postdiagnosis and cancer-specific death (OR 0·99, 95% CI 0·68-1·42), which did not markedly alter after adjustment for confounders including stage (OR 0·87, 95% CI 0·56-1·34). No significant associations were detected for individual beta-blocker types, by defined daily doses of use or for all-cause mortality. CONCLUSIONS: Contrary to some previous studies, beta-blocker use after malignant melanoma diagnosis was not associated with reduced risk of death from melanoma in this U.K. population-based study.

Non-steroidal anti-inflammatory drugs for the treatment of cancer cachexia: a systematic review.

BACKGROUND: Cancer cachexia is a devastating syndrome of advanced malignancy which negatively impacts on patients' morbidity, mortality and quality of life. Chronic inflammation is a key characteristic of cancer cachexia. Therefore, non-steroidal anti-inflammatory drugs (NSAIDs) may be able to break the cycle of cachexia. AIM: To systematically review the literature on the use of NSAIDs for the treatment of cachexia in advanced cancer patients. DESIGN: All titles retrieved through searching were downloaded to a reference management database, duplicates were removed and the remaining citations were checked for eligibility. Full copies of all eligible articles were obtained and reviewed. DATA SOURCES: Electronic searches (from inception up to 09/2011) included CINAHL, MEDLINE, EMBASE, and Web of Science. Reference lists from reviewed articles, trial registers and abstracts from relevant conferences were searched. Eligibility criteria were (a) Randomised Controlled Trial; (b) participants were adults with cancer with weight loss or a clinical diagnosis of cachexia; (c) administration of oral NSAIDs. RESULTS: Four studies were included. These studies provided some evidence of positive therapeutic effect on quality of life, performance status, inflammatory markers, weight gain and survival, but there was insufficient evidence demonstrated for their widespread use in practice. CONCLUSIONS: Insufficient studies have been performed to allow a conclusion to be formed with regard to the effectiveness of NSAIDs in the treatment of cachexia in advanced cancer. Major challenges in this patient cohort include the lack of uniformity of inclusion criteria across studies and the frailty of the patients recruited.

Do perinatal and early life exposures influence the risk of malignant melanoma? A Northern Ireland birth cohort analysis.

AIM: Intrauterine, early life and maternal exposures may have important consequences for cancer development in later life. The aim of this study was to examine perinatal and birth characteristics with respect to Cutaneous malignant melanoma (CMM) risk. METHODS: The Northern Ireland Child Health System database was used to examine gestational age adjusted birth weight, infant feeding practices, parental age and socioeconomic factors at birth in relation to CMM risk amongst 447,663 infants delivered between January 1971 and December 1986. Follow-up of histologically verified CMM cases was undertaken from the beginning of 1993 to 31st December 2007. Multivariable adjusted unconditional logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals (CI) of CMM risk. RESULTS: A total of 276 CMM cases and 440,336 controls contributed to the final analysis. In reference to normal (gestational age-adjusted) weight babies, those heaviest at birth were twice as likely to develop CMM OR 2.4 (95% CI 1.1-5.1). Inverse associations with CMM risk were observed with younger (<25 years) parental age at birth and both a higher birth order and greater household density OR 0.61 (95% CI 0.37-0.99) and OR 0.56 (95% CI 0.30-1.0) respectively. CONCLUSION: This large study of early onset melanoma supports a positive association with higher birth weight (imperatively gestational age adjusted) and CMM risk which may be related to factors which drive intrauterine foetal growth. Strong inverse associations observed with higher birth order and household density suggest that early-life immune modulation may confer protection; findings which warrant further investigation in prospective analyses.

Increased diagnosis and detection rates of carcinoma in situ of the breast.

The purpose of this study was to identify trends in the diagnosis of carcinoma in situ (CIS) of the breast in the United Kingdom (UK) and the Republic of Ireland (ROI) and to examine the impact of mammography. Data on cases of newly diagnosed CIS of the breast and mode of detection (screen detected or not) were obtained, where available, from regional cancer registries between 1990 and 2007. Age-standardised diagnosis rates for the UK and the ROI, and regional screen detected diagnosis rates were compared by calculating the annual percentage change (APC) over time. The APC of the diagnosis rate amongst women aged 50-64 years (original screening age group) showed a significant 5.9% increase in the UK (1990-2007) and 11.5% increase in the ROI (1994-2007). The rate of diagnosis (50-64 years) stabilized in the UK between 2005 and 2007 and was substantially higher than in other western populations with national screening programmes. The APC of the diagnosis rate amongst those aged 65-69 years showed a significant 12.4% increase in the UK (1990-2007) and 10.3% increase in the ROI (1994-2007). amongst women aged 50-74 years in the UK, approximately 4,300 cases of CIS (≈90% ductal carcinoma in situ) were diagnosed in 2007. Our analyses have shown that screen detected CIS contributed primarily to the increase in diagnosis of CIS of the breast. The high diagnosis rate of screen detected CIS of the breast underlines the need for further research into lesion and patient characteristics that are related to progression of CIS to invasive disease to better target treatment.

Vitamin d receptor gene variants and esophageal adenocarcinoma risk: a population-based case-control study.

PURPOSE: Polymorphisms in the vitamin D receptor (VDR) gene may be of etiological importance in determining cancer risk. The aim of this study was to assess the association between common VDR gene polymorphisms and esophageal adenocarcinoma (EAC) risk in an all-Ireland population-based case-control study. METHODS: EAC cases and frequency-matched controls by age and gender recruited between March 2002 and December 2004 throughout Ireland were included. Participants were interviewed, and a blood sample collected for DNA extraction. Twenty-seven single nucleotide polymorphisms in the VDR gene were genotyped using Sequenom or TaqMan assays while the poly(A) microsatellite was genotyped by fluorescent fragment analysis. Unconditional logistic regression was applied to assess the association between VDR polymorphisms and EAC risk. RESULTS: A total of 224 cases of EAC and 256 controls were involved in analyses. After adjustment for potential confounders, TT homozygotes at rs2238139 and rs2107301 had significantly reduced risks of EAC compared with CC homozygotes. In contrast, SS alleles of the poly(A) microsatellite had significantly elevated risks of EAC compared with SL/LL alleles. However, following permutation analyses to adjust for multiple comparisons, no significant associations were observed between any VDR gene polymorphism and EAC risk. CONCLUSIONS: VDR gene polymorphisms were not significantly associated with EAC development in this Irish population. Confirmation is required from larger studies.

Proton pump inhibitors and histamine-2-receptor antagonists and pancreatic cancer risk: a nested case-control study.

BACKGROUND: The relationship between use of proton pump inhibitors (PPIs) and histamine-2-receptor antagonists (H(2)RAs) and pancreatic cancer risk has yet to be examined. Data from a range of studies suggest biologically plausible mechanisms, whereby these drugs (or the conditions for which they are prescribed) may affect pancreatic cancer risk. The objective of this study was to investigate the relationship between use of PPIs/H(2)RAs and pancreatic cancer risk. METHODS: A nested case-control study was conducted within the UK general practice research database (GPRD). Cases had a diagnosis of exocrine pancreatic cancer and controls were matched to cases on general practice site, sex and year of birth. Exposure to PPIs and to H(2)RAs since entry into GPRD until 2 years before the diagnosis date (corresponding date in controls) and in the 5 years before the diagnosis date were separately assessed. Conditional logistic regression analyses were used to generate odds ratios (ORs) and 95% confidence intervals (CIs) associated with PPI or H(2)RA use compared with nonuse. RESULTS: Ever use of PPIs since entry into the GPRD (excluding the 2 years prior to diagnosis) was not associated with risk of pancreatic cancer; OR (95% CI) 1.02 (0.85-1.22). Neither the dose nor the duration of PPI or H(2)RA use was associated with pancreatic cancer risk. No consistent patterns of association were seen when cumulative exposure (dose and duration) to these drugs was examined separately or together. CONCLUSION: PPI/H(2)RA use, in a UK population, was not associated with pancreatic cancer risk.

A systematic review to establish the frequency of cyclooxygenase-2 expression in normal breast epithelium, ductal carcinoma in situ, microinvasive carcinoma of the breast and invasive breast cancer.

BACKGROUND: Epidemiological studies have suggested a protective effect of cyclooxygenase (COX)-inhibiting non-steroidal anti-inflammatory drugs in breast cancer risk and disease progression. We performed a systematic review to evaluate the frequency of COX-2 expression in normal breast epithelium, ductal carcinoma in situ of breast (DCIS), DCIS-adjoining invasive breast cancer, microinvasive carcinoma of the breast (MICB) and invasive breast cancer. METHODS: Literature searches were carried out on MEDLINE, EMBASE and Web of Science from their commencement until September 2010. Primary studies examining COX-2 expression by immunohistochemistry methodology were included. Meta-analyses were carried out using random effects models for individual study estimates of COX-2 expression and pooled to give an overall estimate. RESULTS: The pooled prevalences (95% confidence intervals) of COX-2 expressions were 53% (44-61) in DCIS studies and 42% (36-49) in the invasive breast cancer studies. There were too few studies involving normal breast epithelium, DCIS-adjoining invasive breast cancer and MICB to conduct meta-analyses. CONCLUSION: The findings from our meta-analyses have shown similar COX-2 expression in DCIS and invasive breast cancer. This may suggest the involvement of COX-2 in early carcinogenesis. Further studies of COX-2 expression in DCIS are required to investigate the use of COX-2 as a potential drug target for prevention of disease progression in DCIS.

Non-steroidal anti-inflammatory drugs and pancreatic cancer risk: a nested case-control study.

BACKGROUND: Non-steroidal anti-inflammatory drug (NSAID) use has been linked with pancreatic cancer risk; however, findings from epidemiological studies are inconsistent. METHODS: A nested case-control study was conducted within the UK General Practice Research Database. Cases (n=1141) had a diagnosis of primary cancer of the exocrine pancreas between January 1995 and June 2006. Controls (n=7954) were matched with each case on general practice site, sex and year of birth. Conditional logistic regression analyses were used to generate odds ratios (OR) and 95% confidence intervals (CI) associated with NSAID use compared with non-use. RESULTS: Any use of NSAID in the 5 years before the index date or since entry into the database (excluding the year before diagnosis) was not associated with risk of pancreatic cancer; OR 0.96 (95% CI, 0.84-1.10) and 1.03 (95% CI 0.89-1.19), respectively. Exposure to NSAIDs for > 773 days, in the 5 years pre-diagnosis, was associated with a reduced risk of pancreatic cancer OR 0.78 (95%CI 0.62-0.97). There was evidence of reduced pancreatic cancer risk with long-term use (5 years or more) of lower doses of NSAIDs OR 0.70 (95% CI 0.49-0.99). CONCLUSION: Long-term exposure to NSAIDs may be associated with a reduction in risk of pancreatic cancer.

Is there a benefit from lycopene supplementation in men with prostate cancer? A systematic review.

Lycopene has a chemopreventive effect against prostate cancer but its role in prostate cancer progression is unknown; many patients increase their intake of lycopene, although there are no evidence-based guidelines to suggest an effect. Our objective was to conduct a systematic review of literature to evaluate the association between lycopene intake and prostate cancer progression. MEDLINE, EMBASE CINAHL Plus, Web of Science, AMED and CENTRAL databases were systematically searched using terms for lycopene and prostate cancer progression to identify studies published before January 2009. Eight intervention studies were identified (five with no control group; one with an unmatched control group; and two randomized controlled trials (RCTs)). An inverse association was observed between lycopene intake and PSA levels in six studies. The rates of progression measured by bone scan in one RCT were lower in the intervention group. Lycopene resulted in lowering cancer-related symptoms (pain, urinary tract symptoms), and severe toxicity or intolerance was not evident. However, the evidence available to date is insufficient to draw a firm conclusion with respect to lycopene supplementation in prostate cancer patients and larger RCTs are required in broader patient groups.

Lignans and breast cancer risk in pre- and post-menopausal women: meta-analyses of observational studies.

Phyto-oestrogens are plant compounds structurally similar to oestradiol, which have been proposed to have protective effects against breast cancer. The main class of phyto-oestrogens in the Western diet is lignans. Literature reports on the effect of lignans in breast cancer risk have been conflicting. We performed three separate meta-analyses to examine the relationships between (i) plant lignan intake, (ii) enterolignan exposure and (iii) blood enterolactone levels and breast cancer risk. Medline, BIOSIS and EMBASE databases were searched for publications up to 30 September 2008, and 23 studies were included in the random effects meta-analyses. Overall, there was little association between high plant lignan intake and breast cancer risk (11 studies, combined odds ratio (OR): 0.93, 95% confidence interval (95% CI): 0.83-1.03, P=0.15), but this association was subjected to marked heterogeneity (I(2)=44%). Restricting the analysis to post-menopausal women, high levels of plant lignan intake were associated with reduced breast cancer risk (7 studies, combined OR: 0.85, 95% CI: 0.78, 0.93, P<0.001) and heterogeneity was markedly reduced (I(2)=0%). High enterolignan exposure was also associated with breast cancer (5 studies, combined OR: 0.73, 95% CI: 0.57, 0.92, P=0.009) but, again, there was marked heterogeneity (I(2)=63%). No association was found with blood enterolactone levels (combined OR: 0.82, 95% CI: 0.59-1.14, P=0.24). In conclusion, plant lignans may be associated with a small reduction in post-menopausal breast cancer risk, but further studies are required to confirm these results.

Second primary cancers in patients with skin cancer: a population-based study in Northern Ireland.

Among all 14,500 incident cases of basal cell carcinoma (BCC), 6405 squamous cell carcinomas (SCC) and 1839 melanomas reported to the Northern Ireland Cancer Registry between 1993 and 2002, compared with the general population, risk of new primaries after BCC or SCC was increased by 9 and 57%, respectively. The subsequent risk of cancer, overall, was more than double after melanoma.

Components of variation in serum carotenoid concentrations: the Polyp Prevention Trial.

OBJECTIVES: The intra- and interindividual variations and season and center effects were estimated from a series of serum carotenoid concentrations in the Polyp Prevention Trial (PPT) participants. SUBJECTS/METHODS: Fasting blood was collected annually for 4 years in all 1905 participants, and a subcohort of 901 participants were selected within each (of eight) center(s), by gender and dietary arm of the study, for measurement of five major carotenoid peaks. Using variance of component methods, the variation in serum carotenoid concentrations about the underlying mean was partitioned into explanatory components attributed to various sources. RESULTS: The contributions of the inter- and intraindividual variances to the overall variation in carotenoid concentrations were in the range of 61-70 and 20-35%, respectively, whereas center and center-by-season effects provided 2.6-9.5 and 0.2-1.4%, respectively. The highest percent (35%) of intraindividual variation was exhibited by lycopene, and the highest percent (70% apiece) of interindividual variation was exhibited by lutein/zeaxanthin and beta-carotene. Serum lycopene had the highest ratio of intra- to interindividual variation of 0.57, whereas lutein had the lowest ratio of 0.29. We estimate that the ratio of intra- to interindividual variance around the mean carotenoid concentration can be reduced greatly by collecting 3-4 compared to 1 blood measurement in large-scale trials like the PPT. CONCLUSION: In the largest study of components of variation in individuals at high risk for colorectal cancer, the largest contributors to variation in serum carotenoid concentrations were intra- and interindividual effects followed by center and center-by-season effects.

Dietary glycaemic index, glycaemic load and breast cancer risk: a systematic review and meta-analysis.

This systematic review aimed to examine if an association exists between dietary glycaemic index (GI) and glycaemic load (GL) intake and breast cancer risk. A systematic search was conducted in Medline and Embase and identified 14 relevant studies up to May 2008. Adjusted relative risk estimates comparing breast cancer risk for the highest versus the lowest category of GI/GL intake were extracted from relevant studies and combined in meta-analyses using a random-effects model. Combined estimates from six cohort studies show non-significant increased breast cancer risks for premenopausal women (relative risk (RR) 1.14, 95% CI 0.95-1.38) and postmenopausal women (RR 1.11, 95% CI 0.99-1.25) consuming the highest versus the lowest category of GI intake. Evidence of heterogeneity hindered analyses of GL and premenopausal risk, although most studies did not observe any significant association. Pooled cohort study results indicated no association between postmenopausal risk and GL intake (RR 1.03, 95% CI 0.94-1.12). Our findings do not provide strong support of an association between dietary GI and GL and breast cancer risk.

Association of early life factors and brain tumour risk in a cohort study.

Using population-based linked birth and cancer registry data, we investigated whether the risk of brain tumour in childhood (n=155) was associated with perinatal risk factors. This population-based cohort showed that being born into a larger family or to a mother with a history of miscarriage may increase childhood brain tumour risk.

Dietary glycaemic index, glycaemic load and endometrial and ovarian cancer risk: a systematic review and meta-analysis.

Long-term consumption of a high glycaemic index (GI) or glycaemic load (GL) diet may lead to chronic hyperinsulinaemia, which is a potential risk factor for cancer. To date, many studies have examined the association between GI, GL and cancer risk, although results have been inconsistent, therefore our objective was to conduct a systematic review of the literature. Medline and Embase were systematically searched using terms for GI, GL and cancer to identify studies published before December 2007. Random effects meta-analyses were performed for endometrial cancer, combining maximally adjusted results that compared risk for those in the highest versus the lowest category of intake. Separate analysis examined risk by body mass index categories. Five studies examining GI and/or GL intake and endometrial cancer risk were identified. Pooled effect estimates for endometrial cancer showed an increased risk for high GL consumers (RR 1.20; 95% CI: 1.06-1.37), further elevated in obese women (RR 1.54; 95% CI: 1.18-2.03). No significant associations were observed for GI. Only two studies examined ovarian cancer and therefore no meta-analysis was performed, but results indicate positive associations for GL also. A high GL, but not a high GI, diet is positively associated with the risk of endometrial cancer, particularly among obese women.

A longitudinal study of infant feeding and obesity throughout life course.

BACKGROUND: The Centers for Disease Control and Prevention and the US Department of Health and Human Services promote breastfeeding as a strategy for reducing childhood overweight. We evaluated the relation between infant feeding and the development of overweight and obesity throughout life course. METHODS: We investigated the association between infant feeding and obesity among 35,526 participants in the Nurses' Health Study II who were followed prospectively from 1989 to 2001. Mothers of participants provided information by mailed questionnaires on the duration of breast- and bottle-feeding, as well as the type of milk or milk substitute in the bottle. Information on body shape at ages 5 and 10, weight at age 18, current weight between 1989 and 2001, and height was reported by the participants. RESULTS: The duration of breastfeeding, including exclusive breastfeeding, was not related to being overweight (25< or = body mass index (BMI) <30 kg/m(2)) or obese (BMI> or =30 kg/m(2)) during adult life. Women who were exclusively breastfed for more than 6 months had a risk of 0.94 (95% confidence interval (CI) 0.83-1.07) of becoming obese as adults compared with women who were not breastfed. Exclusive breastfeeding for more than 6 months was associated with leaner body shape at age 5 (odds ratio (OR)=0.81; 95% CI 0.65-1.01 for the highest vs the lowest category of body shape) compared to women who were not breastfed or breastfed for less than 1 week, but this association did not persist during adolescence or adulthood. CONCLUSIONS: We did not find that having been breastfed was associated with women's likelihood of becoming overweight or obese throughout life course. Although breastfeeding promotes the health of mother and child, it is unlikely to play an important role in controlling the obesity epidemic.

Contribution of foods to trans unsaturated fatty acid intake in a group of Irish adults.

OBJECTIVE: To assess fat intake with particular focus on trans unsaturated fatty acid (TUFA) intake and the major sources of TUFA among Irish individuals using a Fat Intake Questionnaire (FIQ), designed specifically for an Irish context. SUBJECTS AND METHODS: A total of 105 healthy volunteers (43 females, 62 males; aged 23-63 years) were recruited from Dublin Airport Medical centre, Republic of Ireland. Dietary intake was assessed using an 88 food item/food group semi-quantitative FIQ, which was developed and validated for the Irish population. RESULTS: Mean energy intake was 10.6 MJ day(-1), and 34% was provided by fat. Saturated, monounsaturated, polyunsaturated, trans unsaturated fatty acids and linoleic acid contributed 13%, 10%, 6%, 2% and 5% of energy respectively. Mean TUFA intake was 5.4 g day(-1) (range 0.3-26). Margarine spreads provided the majority of TUFAs (1.93 g day(-1)), but the contribution was significantly greater for men compared with women (2.35 g day(-1) versus 1.33 g day(-1); P = 0.024). Milk and meat also contributed more to TUFA intake for men compared with women, but confectionery was a significantly greater contributor for women (8.6% versus 3.1% respectively, P = 0.01). CONCLUSIONS: Although the mean TUFA intake of the total group was 5.4 g day(-1) and was within current dietary recommendations (2% energy intake), some individuals had intakes as high as 26 g day(-1). Public health efforts are therefore required to reduce TUFA intake in those individuals with high intakes.

Assessment of individual fatty acid intake.

Dietary assessment of individual fatty acid intake is difficult due to a number of limitations. Information regarding the type, quantity and brand-name of fat used in cooking and at the table is required. In addition, margarine manufacturers may change the component oils used for reasons of cost, which changes the fatty acid composition of their products from season-to-season. Independent markers of fatty acid intake are required, therefore, to compensate for these limitations. Adipose tissue concentrations have been used as a measure of habitual intake of fatty acid groups and individual fatty acids in numerous studies. Saturated (SFA) and monounsaturated fatty acids (MUFA) are generally poorly correlated with adipose tissue concentrations, which can be explained partly by endogenous synthesis. In general, adipose tissue concentrations of exogenously-produced fatty acids (n-3 and n-6 polyunsaturated fatty acids (PUFA)) are well correlated with estimates of habitual intake. Correlations between dietary trans unsaturated fatty acids (TUFA) and adipose tissue concentrations vary between countries, which may be due to differences in dietary sources. Correlations may be affected by differences in bioavailability or selective retention of fatty acids in certain tissue lipids.