Short-term effectiveness of mandatory iodization of table salt, at an elevated iodine concentration, on the iodine and goiter status of schoolchildren with endemic goiter.

BACKGROUND: Goiter rates and iodine deficiency usually show marked improvement in efficacy studies of mandatory iodization of salt, but little is known about the short-term effectiveness of mandatory iodization. OBJECTIVE: The aim of the study was to evaluate, after 1 y, the effectiveness of mandatory iodization of salt at an iodine concentration higher than that occurring under optional iodization on the goiter rates and iodine status of schoolchildren living in an endemically goitrous area. DESIGN: Goiters, measured by palpation, and urinary iodine concentrations of children in grades 4-7 in 4 schools in a known goitrous area in South Africa were assessed before and 1 y after the introduction of mandatory iodization at a higher iodine concentration than occurred with optional iodization. Estimates of the iodine concentration of iodized salt and the proportion of households using iodized salt were also made. RESULTS: Iodine concentration in table salt and household use of iodized salt improved within 1 y. Goiter rates, which varied at baseline from 14. 3% to 30.2% in the 4 schools, remained unchanged, with an overall mean (+/-SE) prevalence of 25.6 +/- 2.5% at baseline and of 27.5 +/- 2.7% 1 y later. The distribution of urinary iodine concentrations in the 4 schools improved substantially from the baseline deficient range. The overall median urinary iodine concentration increased from 0.17 to 1.47 micromol/L. CONCLUSIONS: Mandatory iodization of salt virtually eradicated iodine deficiency within 1 y in South African schoolchildren, but the goiter rate in these children did not decline. Measurement of goiters by palpation may not be appropriate in short-term evaluations of mandatory iodization programs.

Biodistribution of 131I-radiolabelled plasma low density lipoprotein in hyperlipidaemic vervet monkeys.

Low density lipoprotein (LDL) labelled with 131I has been administered to 6 Vervets 2 of which were high responders to an atherogenic Western diet in terms of plasma cholesterol, 2 were low responders and 2 were fed a high carbohydrate control diet. The ratio of hepatic to cardiac activity was recorded for up to 10 days after administration of the labelled LDL. Liver activity had a longer biological half life in the high-responders and this can be interpreted in terms of a variation of hepatic metabolism of LDL, with direct relevance to the human situation.

Promotion and regression of atherosclerosis in vervet monkeys by diets realistic for westernized people.

We have described and measured aortic and arterial atherosclerosis in adult female Vervet monkeys (n = 61) after application of dietary treatments for 47 months. The diets were compounded entirely of normal food items for westernized people, with no extra cholesterol added. A 'Western' diet (WD), known to induce hypercholesterolaemia, was found to be atherogenic in aortas and some arteries. A more 'prudent' diet (PD) induced much less lipid infiltration into aortic intimas and was not associated with serious atherosclerotic changes. However, when this PD was used as a treatment for 27 months, following 20 months of nutrition by the WD, minimal regression of cholesterol crystals and non-lipid components of atherosclerotic plaque was detected. There was no significant coronary artery or myocardial disease in these adult females after 47 months of feeding on the WD whereas males do develop coronary atherosclerosis and myocardial fibrosis. For this model the PD would be more effective in preventing atherosclerosis than treating advanced lesions. We believe this is the first time that the pathology of atherosclerosis promoted by realistic diets has been modelled in adult females of this species.

Diets realistic for westernized people significantly effect lipoproteins, calcium, zinc, vitamins C, E, B6 and haematology in vervet monkeys.

This report describes measurements of 50 variables in adult, female, reproductively inactive Vervet monkeys during prolonged nutrition realistic for westernized people. Dietary treatments consisted of an atherogenic Western diet (WD) and a prudent Western diet (PD). Ingredients were normal foods for man and no extra cholesterol was added. Fortification of both diets with vitamin C after cooking was necessary to prevent deficiency. Randomised groups of Vervet monkeys received either the PD or WD for 47 months, while a third group was fed WD for 20 months and then PD for 27 months (WD-PD). Before the dietary treatments nourishment was by a high carbohydrate diet (HCD) and baseline and reference values (RV) apply to this nutritional status. Plasma total cholesterol (mg/dl) was increased from 147 (HCD) to 174 (PD) and 376 (WD). Individual cholesterolaemio response ranged from mild to severe and was stable (PD and WD). Dietary reversal (WD-PD) reduced cholesterolaemia promptly. Statistically significant increases in calcium, zinc and vitamin E and decreased vitamin B6 were associated with the WD relative to the PD (in serum and plasma). Two cholesterol metabolising microsomal enzymes in liver were notably increased and one unchanged (WD). There were no dietary effects on triglycerides, vitamin A and glucose in plasma; insulin, glucagon, electrolytes, copper, magnesium or enzymes reflecting liver, muscle or brain cell damage in serum. Red blood cells, platelets and directly associated parameters increased (WD), haemoglobin was the same and haemoglobin per red cell decreased. Bleeding time was not affected. Bivariate correlations across the diets confirmed that Western nutrition promoted inherent individual susceptibility to cholesterolaemia. There were notable differences from RVs in total cholesterol, calcium, packed cell volume and haemoglobin, which emphasise excesses and deficiencies of the WD and PD.

Plasma low density lipoprotein composition in relation to atherosclerosis in nutritionally defined Vervet monkeys.

An atherogenic diet (AD) consisting entirely of normal foods for westernized people was fed to female Vervet monkeys for 4 years. The plasma low density lipoprotein (LDL) cholesterol pool was increased and progression of atherosclerosis was enhanced by the AD compared to a more prudent Western diet. The increased LDL-cholesterol was carried by a 3-fold increase in particles of relatively normal composition and not by packing cholesterol esters into the cores of enlarged LDL particles, as has been reported after feeding semisynthetic diets loaded with extra cholesterol. Nevertheless, these LDL particles were atherogenic. The AD changed the fatty acid composition of LDL-cholesterol esters and triacylglycerol, notably by increasing arachidonic and reducing linoleic acid. Multivariate analysis showed that measures and scores of atherosclerosis were significantly dependent on sphingomyelin and phosphatidylcholine in LDL and on arachidonic acid in LDL-triacylglycerol. Although apolipoprotein B, free cholesterol, esterified cholesterol and lysophosphatidylcholine in plasma LDL and atherosclerosis were significantly positively correlated in bivariate analysis they were not selected by multivariate analysis as the strongest determinants of atherogenesis. Cholesterol in plasma high density lipoprotein was not changed by the AD and lecithin:cholesterol acyltransferase activity in plasma was inversely linked to atherosclerosis. Subcutaneous fatty acids reflected dietary fatty acids.

Low density lipoprotein kinetics in African Green monkeys showing variable cholesterolaemic responses to diets realistic for westernised people.

African Green (vervet) monkeys were fed either an atherogenic Western diet (WD), a prudent diet (PD), or a high carbohydrate diet (HCD) for various lengths of time. Monkeys differed greatly in their response to the WD, and a strong negative correlation was observed between the fractional catabolic rates (FCR) of low density lipoprotein (LDL) and the total plasma cholesterol concentrations (r = -0.83 P = 0.0029). Similarly the individual synthetic rates (SR) of LDL plotted against the total plasma cholesterol concentrations showed a correlation coefficient of r = 0.94 P = 0.01 for WD animals. There was no correlation for PD or HCD animals for either SR or FCR and the total plasma cholesterol concentrations. The aortic lesion scores correlated with the SRs (r = 0.66 P = 0.040) but not with the FCRs. LDL turnover was also studied using 125I-labelled native LDL and methylated 131I-labelled LDL in African Green monkeys showing high or low cholesterolaemic response to an atherogenic Western diet. Measurements after 4 weeks and again after 6 months on the diet showed a decrease in both total and non-receptor mediated clearance of LDL. Receptor-mediated catabolism was significantly lowered in the hyperresponding group (P = 0.0011) and not in the hyporesponding group with a resultant significant difference between the two groups being P = 0.0355 after 6 months. Non-receptor mediated catabolism of LDL was similarly affected in that there was no significant difference between the two groups at 4 weeks but the clearance of methylated LDL was markedly lowered at 6 months, for the hyporesponding group P = 0.0003 and for the hyperresponding group P = 0.0184. Furthermore the hyperresponding group was depressed to a significantly greater extent when compared to the hyporesponding group (P = 0.0241).

Atherogenic effects in a non-human primate of Fusarium moniliforme cultures added to a carbohydrate diet.

Adding less than 0.5% w/w of culture material of strain MRC 826 of the fungus Fusarium moniliforme to a carbohydrate diet low in fat resulted in an atherogenic plasma lipid profile in a non-human primate. Simultaneously increased plasma fibrinogen and activity of blood coagulation factor VII could enhance atherogenesis. This unique potential for promotion of atherosclerosis was probably secondary to chronic hepatotoxicity as indicated by liver fibrosis and elevated cholesterol, albumin and the enzymes AST, ALT, LD, GGT and ALP in serum. The cholesterol and enzymes responded in proportion to the calculated doses of fumonisin mycotoxins in the F. moniliforme MRC 826 cultures. Fumonisins are water soluble and heat stable. Thrombotic, hepatotoxic, carcinogenic and cerebral effects of MRC 826 culture material and fumonisins are well known in non-primates. The estimated fumonisin concentrations tested fall within a range due to natural contamination of human foods. The results suggest that all maize grain products should be analysed for fumonisins.

Free cholesterol concentrations in the high-density lipoprotein subfraction-3 as a risk indicator in patients with angiographically documented coronary artery disease.

BACKGROUND: The pathophysiology of plasma lipoprotein metabolism has long been linked to coronary artery disease (CAD). The present study evaluated the association between plasma lipoprotein lipid and apolipoprotein (apo) components and CAD in a group of 80 consecutive Caucasian patients undergoing coronary angiography. METHODS: Coronary cineangiography was carried out using the Judkins technique and the lesions quantified by calculating a coronary artery lesion score (CALS). Very low- and low-density lipoproteins (VLDL and LDL) were separated by ultracentrifugation, and high-density lipoprotein (HDL) and HDL subfraction-3 (HDL3) isolated by a differential precipitation procedure. Apo A-I, A-II, and B were assayed by endpoint laser nephelometry using specific antibodies. Total cholesterol, free cholesterol, and fatty acid concentrations were measured by gas-liquid chromatography, and lecithin: cholesterol acyltransferase (LCAT) activity by the decrease in the concentration of free cholesterol. RESULTS: On the basis of the presence of CAD, the 80 patients were divided into two groups: 52 (65%) with CAD (mean CALS = 7.8) and 28 (35%) without CAD (zero CALS). The lipoprotein fraction that most clearly differentiated the groups was HDL cholesterol concentration, with a mean +/- SEM value of 36.5 +/- 1.5 mg/dl for those with CAD and 45.1 +/- 2.1 mg/dl for those without (P < 0.01). The mean HDL3 cholesterol concentration was 29.9 +/- 1.2 mg/dl for patients with CAD and 37.4 +/- 1.8 mg/dl for those without (P < 0.001). These differences in HDL cholesterol and HDL3 cholesterol were mainly caused by differences in the free cholesterol component, with a mean HDL free cholesterol level of 10.8 +/- 1.1 and 16.1 +/- 1.4 mg/dl (P < 0.01), and a mean HDL3 free cholesterol level of 7.6 +/- 0.6 and 11.9 +/- 0.8 mg/dl (P < 0.001) in patients with and without CAD, respectively. Plasma LCAT activity was decreased in patients with CAD (P < 0.05), as were the apo A-I and A-II concentrations in both the HDL (P < 0.001) and HDL3 (P < 0.001) fractions. No significant association was found between CAD and HDL2 cholesterol or plasma total cholesterol, LDL cholesterol, or VLDL cholesterol concentrations. A stepwise discriminant analysis revealed that HDL3 free cholesterol was the only variable selected. Using HDL3 free cholesterol as a screening variable for CAD (cutoff 10.55 mg/dl), the sensitivity for CAD was 87% and the specificity for non-CAD 67%. The positive and negative predictive values of HDL3 free cholesterol were 82 and 75%, respectively. CONCLUSION: We have shown that the concentrations of HDL cholesterol and HDL3 most clearly differentiated between patients with and without CAD.

Endemic goitre in the absence of iodine deficiency in schoolchildren of the Northern Cape Province of South Africa.

OBJECTIVE: The study was undertaken to investigate whether endemic goitre still exists in the Northern Cape Province of South Africa more than 55 years after it was reported and, if so, whether iodine deficiency, or fluoride in the drinking water, is linked to the goitres. DESIGN: Cross-sectional study of children in three pairs of towns. SUBJECTS: The 6-, 12- and 15-year-old children (n = 671) who had been lifetime residents in two Northern Cape towns with low levels, two towns with near optimal levels and two towns with high levels of fluoride in the drinking water were recruited through the schools as study participants. RESULTS: Endemic goitre was found in all the towns except one, ranging from 5% to 29%. Iodine deficiency did not prevail in the study area because the median urinary iodine concentration, exceeding 1.58 micromol/l in all but one of the towns, indicated a more than adequate iodine consumption. The drinking water and, to a lesser extent, iodised salt were important sources of iodine. No relationship was found between fluoride in the water and the mild goitre prevalence (5% to 18%) in the four towns with either a low or near optimal fluoride content in the water. The causal factor(s) responsible for the goitres in these four towns were not clear from our data. However, the prevalence of goitre was higher (28% and 29%) in the two towns with high levels of fluoride in the water. CONCLUSION: These results indicate that either a high fluoride level in the water or another associated goitrogen, other than iodine deficiency, may have been responsible for these goitres.

Lecithin:cholesterol acyltransferase activity and high-density lipoprotein subfraction composition in type 1 diabetic patients with improving metabolic control.

On initial diagnosis or when metabolic control is poor, subjects with type 1 (insulin-dependent) diabetes mellitus often exhibit decreased high density lipoprotein (HDL) cholesterol levels, which have been associated in numerous studies in non-diabetic subjects with atherosclerosis and coronary artery disease. We measured the activities of plasma lecithin:cholesterol acyltransferase (LCAT), post-heparin lipoprotein lipase, and the composition of the HDL subfractions HDL2 and HDL3, in ten poorly controlled type 1 diabetic patients admitted to a metabolic ward (six women and four men, aged 18-37 years). The measurements were repeated after metabolic control had been optimised and again a week after discharge. The results were compared with those of ten healthy normolipidaemic subjects matched for age, sex and body mass. LCAT activity increased significantly (P < 0.05) with improved metabolic control in the diabetic patients, and showed positive within-person correlation with HDL2 cholesterol ester (r = 0.67; P < 0.01), HDL2 free cholesterol (r = 0.67; P < 0.01), phosphatidylcholine (r = 0.49; P < 0.05), total phospholipids (r = 0.50; P < 0.01) and apolipoprotein A-I (apo A-I: r = 0.72; P < 0.01). With improving metabolic control HDL2 lipid levels increased more than twofold and the compositional changes in HDL2 were reflected by an increased apo A-I:apo A-II ratio (P < 0.05) and a decreased triglyceride:apo A-I ratio (P < 0.05). Changes in HDL3 levels and composition were minor. The results of this study indicate that an increase in LCAT activity increases the concentration and changes the composition of HDL2 in type 1 diabetic patients with improved metabolic control.

Cholesterol-ascorbic acid interactions in guinea pig liver homogenates, and in the in situ perfused liver: relationship between ascorbic acid status and cholesterol and bile acid synthesis from mevalonate.

Cell free homogenates, and in situ perfused livers were used to study cholesterol synthesis and catabolism in control and latently scorbutic guinea pigs. In the homogenate studies, cholesterol synthesis from (2-14C) mevalonate was significantly depressed in latently scorbutic guinea pigs when compared to controls (0.02 less than p less than 0.05). Synthesis of cholesterol from (1-14C) acetate and n (1-14C) octanoate was minimal in guinea pigs. In the in situ liver perfusions, the synthesis of cholesterol from (2-14C) mevalonate was 40% lower in latently scorbutic guinea pigs than in control animals (p less than 0.005). The synthesis of cholesterol from (1-41C) acetate did not show the same clear cut effect. Bile acid production in the in situ perfused liver was unexpectedly higher in the latently scorbutic animals than in control animals (p = 0.005), although the incorporation of the label from (2-14C) mevalonate into the bile acids from the two groups was not significantly different. This finding led to the latently scorbutic group having a far lower specific activity in the bile acid fraction than the replete group.

Iodine deficiency and endemic goitre in the Langkloof area of South Africa.

OBJECTIVE: To quantify the prevalence of iodine deficiency and endemic goitre in the Langkloof area. DESIGN: A cross-sectional study. SETTING: Four primary schools in four communities in the Langkloof. SUBJECTS: 565 primary schoolchildren from Standard 2 to Standard 5. OUTCOME MEASURES: Clinical diagnosis of thyroid size by palpation, level of iodine in urine and drinking water samples, level of iodine in iodised salt samples from the area, percentage of households with iodised salt on the premises, and anthropometric measures of body height and weight. RESULTS: The prevalence of endemic goitre varied from 14.3% to 30.2% in the four communities and, based on urinary iodine levels, the iodine deficiency ranged from mild to severe. Both iodised and non-iodised salt were available at the local grocery stores but only small percentages of households had iodised salt in the house. The iodine content of drinking water was low. Anthropometric indices of undernutrition indicated medium to high levels of stunting in three of the four communities, the worst being in the community with the highest goitre prevalence. CONCLUSIONS: Endemic goitre caused by iodine deficiency is a public health problem in the Langkloof, varying in severity from mild to severe in the different communities. The impact of mandatory iodisation of table salt, introduced at the end of 1995, needs to be assessed in these communities.

Iodine concentration in household salt in South Africa.

OBJECTIVE: To determine the iodine concentration in household salt, the coverage of adequately iodized salt, the use of non-iodized agricultural and producers' salt, and the usefulness of salt as a carrier of iodine, and to relate these observations to socioeconomic status in South Africa. METHOD: The iodometric titration method was used to analyse 2043 household salt samples collected using a national, multistage, stratified, cluster survey. FINDINGS: The national mean and median iodine concentrations of household salt were 27 mg/kg (95% confidence interval (CI): 25-29 mg/kg) and 30 mg/kg (range = 0-155 mg/kg), respectively. There was considerable variation within and between geographical areas. Coverage of adequately iodized household salt, i.e. iodized at > 15 mg/kg, was 62.4% of households (95% CI: 58.8-66.0%) two years after the introduction of compulsory iodization at a level of 40-60 mg/kg. A total of 7.3% of households used non-iodized agricultural salt and salt obtained directly from producers. People at the lower end of the socioeconomic spectrum were more likely to suffer the consequences of using under-iodized salt because more of them used agricultural or coarse salt than did people in the higher socioeconomic categories. The iodine concentration in salt was lower in rural areas than in urban and periurban areas. CONCLUSIONS: The consequences of using under-iodized or non-iodized salt were most likely to be experienced in the country's three northern provinces, among people in the low socioeconomic categories, and in rural households. Since 95.4% of households in South Africa use salt regularly and 2.9% use it occasionally, the national iodization programme has the potential to meet the iodine requirements of the population. However, this can only be achieved if the primary reasons for the inadequate iodization of salt are eliminated and if special attention is given to vulnerable groups.

A comparison of the effects of soya-bean protein and casein on bile composition, cholelithiasis and serum lipoprotein lipids in the vervet monkey (Cercopithecus aethiops).

1. Two groups of vervet monkeys (Cercopithecus aethiops) were fed on high-cholesterol diets which differed only with respect to the protein source. In one group casein was the only protein source, while the other group received only soya-bean protein. 2. Samples of blood, bile and liver biopsy material were collected at the commencement of the study and at 3-monthly intervals until termination 12 months later. 3. At the end of the experimental period all the animals (n 19) had high plasma cholesterol levels and had developed pigment gallstones, the compositions and weights of which were not related to the protein source or to plasma cholesterol levels. Gallstone weight was related to the presence of acidic and sulphated mucins in gallbladder mucosa. We were also unable to confirm the hypocholesterolaemic effect of soya-bean protein which has been demonstrated previously in rhesus monkeys and hamsters. Bile composition and plasma lipids did not differ significantly between the casein-fed and soya-bean fed animals. Lithogenic index was below 1 for both groups and did not differ significantly between the two groups. 4. No significant difference was found in the severity of cholelithiasis between the casein-fed and the soya-bean-fed animals.

Impact after 1 year of compulsory iodisation on the iodine content of table salt at retailer level in South Africa.

The short-term effectiveness of introducing compulsory iodisation through revised health legislation, evaluated in terms of the iodine content of iodised table salt, was investigated in three of the nine provinces in South Africa. Shortly before the introduction of compulsory iodisation of table salt in December 1995, iodised at a higher level than before, 187 iodised salt samples were purchased at retailers in 48 magisterial districts situated in the three provinces of Western and Eastern Cape and Mpumalanga for analysis of the iodine content using the titration method. In a follow-up 1 year later 287 iodised salt samples were obtained from the same retailers for iodine determination. The mean iodine content of iodised salt increased significantly from 14 to 33 ppm. However, large variation in the iodine content of iodised table salt among and within salt brands existed at follow-up, and the mean iodine content was lower than the legal specification of 40 to 60 ppm. Only 24% of the samples were found within the range required by the law at follow-up compared to 42% before revising the salt legislation. Despite the introduction of compulsory salt iodisation, the mean retail price of iodised salt remained the same between 1995 and 1996 for a 500 g package of salt. Further refinement of the iodisation process is necessary to improve the accuracy of iodisation and decrease the variation in iodine content. This study nevertheless showed that the introduction of compulsory iodisation and elevating the legally specified iodine level of table salt resulted in a significantly elevated mean iodine level of iodised salt within 1 year, without any additional cost to the consumer.

The use of low density lipoprotein receptor activity of lymphocytes to determine the prevalence of familial hypercholesterolaemia in a rural South African community.

The diagnosis of heterozygous familial hypercholesterolaemia in three rural South African communities in which hypercholesterolaemia is very prevalent could be confirmed by the measurement of low density lipoprotein (LDL) receptor activity in circulating lymphocytes. A nominal cut off point could be proposed which separated the LDL receptor activity of 24 clinically diagnosed heterozygous FH patients and 31 healthy people. LDL receptor activity was measured as total degradation of 125I-LDL and expressed as ng LDL/mg cell protein/6 hours. The cut off point was set at 970 ng/mg protein/6 hours. This proposed cut off point was tested by assaying the LDL receptor of three homozygous FH patients and seven of their obligate heterozygous FH first degree relatives. The three homozygous FH patients showed no receptor activity and the activity of the seven obligate heterozygous first degree relatives fell below the proposed cut off point. To determine the prevalence of FH in the study population, all persons aged 15 to 24 years whose total cholesterol levels fell above the 80th centile for their age and sex, as well as their families, were approached (n = 114). The LDL receptor activity in lymphocytes of 77 of these persons aged 15 to 24 years was determined after applying the exclusion criteria. Ten of the 77 participants had LDL receptor activity below 970 ng LDL/mg protein/6 hours and were therefore diagnosed as being heterozygous FH patients. The calculation of the prevalence (corrected for exclusions) revealed that one in 71 of the 15 to 24 year old permanent residents in the predominantly Afrikaans speaking community suffered from heterozygous FH. This is higher than any FH prevalence previously reported for any group.

Ethanol drinking by vervet monkeys (Cercopithecus pygerethrus): individual responses of juvenile and adult males.

Unrestricted access of vervet monkeys to a palatable solution of ethanol resulted in chronic intake or abstinence. Self-selected dose averaged 4.42 g/kg body mass/day. Growth of juveniles was not grossly affected. In plasma, chronic ethanol intake was associated with lower average K and Cl values, increased gamma glutamyl transpeptidase in some adults, and higher average total cholesterol. Neither hepatic histology nor haematology were affected by chronic ethanol intake.

Alcohol intake in relation to lipids, lipoproteins and blood pressure.

A cross-sectional population study of 655 men and 731 women was undertaken to evaluate the association between the level of alcohol intake, the level of high-density lipoprotein cholesterol (HDL-C) and its subfractions, and blood pressure in men and women in different age groups (20-44 and 45-64 years). Habitual alcohol intake was significantly related to higher levels of HDL-C in both men and women. In the case of men both HDL2-C and HDL3-C levels were raised, while in women this rise was restricted almost entirely to HDL2-C. Plasma apolipoprotein A-I and A-II levels were elevated in men who drank, but not in women. In both, triglyceride and blood pressure levels were raised with habitual alcohol intake, and the increases in HDL subfractions and blood pressure levels became more marked with increasing age in both men and women. Recent alcohol intake had less effect on all the variables except blood pressure. We conclude that both HDL3-C and HDL2-C contribute to the rise in HDL-C levels that accompanies alcohol use, notwithstanding differences in the responses of the sexes. A regular alcohol intake is more likely to be beneficial and some of the positive or protective aspects of alcohol consumption could be reduced by the adverse changes in triglycerides and blood pressure levels.