Handb Exp Pharmacol – 2013;(216):133-46.
Sphingolipid metabolism and atherosclrosis.
Department of Cell Biology, SUNY Downstate Medical Center, Brooklyn, NY 11203, USA.
ABSTRACT: Atherosclerosis is the major cause of mortality in the developed countries. Although presently known risk factors have some predictive value for the disease, a major part of the variability in this process remains unexplained. It is extremely important to find new approaches for better understanding of the disease and for treating it. Exploration of the sphingolipid metabolism is one of these approaches. Sphingolipids are a large class of lipids with structural and signaling functions. Recent researches indicated that these lipids play important roles in the development of atherosclerosis. In this chapter, we summarized the major findings in the field.
J Clin Invest. 2013 Apr 1;123(4):1784-97.
Myeloid cell-specific serine palmitoyltransferase subunit 2 haploinsufficiency reduces murine atherosclerosis.
Department of Cell Biology, State University of New York Downstate Medical Center, New York, New York, USA.
ABSTRACT: Serine palmitoyltransferase (SPT) is the first and rate-limiting enzyme of the de novo biosynthetic pathway of sphingomyelin (SM). Both SPT and SM have been implicated in the pathogenesis of atherosclerosis, the development of which is driven by macrophages; however, the role of SPT in macrophage-mediated atherogenesis is unknown. To address this issue, we have analyzed macrophage inflammatory responses and reverse cholesterol transport, 2 key mediators of atherogenesis, in SPT subunit 2-haploinsufficient (Sptlc2(+/-)) macrophages.
We found that Sptlc2(+/-) macrophages have significantly lower SM levels in plasma membrane and lipid rafts. This reduction not only impaired inflammatory responses triggered by TLR4 and its downstream NF-κB and MAPK pathways, but also enhanced reverse cholesterol transport mediated by ABC transporters. LDL receptor-deficient (Ldlr(-/-)) mice transplanted with Sptlc2(+/-) bone marrow cells exhibited significantly fewer atherosclerotic lesions after high-fat and high-cholesterol diet feeding. Additionally, Ldlr(-/-) mice with myeloid cell-specific Sptlc2 haploinsufficiency exhibited significantly less atherosclerosis than controls. These findings suggest that SPT could be a novel therapeutic target in atherosclerosis.
Am J Cardiovasc Dis.2013;3(1):17-26.
Interaction between sphingomyelin and oxysterols contributes to atherosclerosis and sudden death.
Burnsides Research Laboratory, Department of Comparative Biosciences, College of Veterinary Medicine, University of Illinois 1208 W. Pennsylvania Avenue, Urbana, IL 61801, USA.
ABSTRACT: Despite major public health efforts, coronary heart disease continues to be the leading cause of death in the United States. Oxidized lipids contribute to heart disease both by increasing deposition of calcium on the arterial wall, a major hallmark of atherosclerosis, and by interrupting blood flow, a major contributor to heart attack and sudden death. Oxidized cholesterol (oxysterols) enhances the production of sphingomyelin, a phospholipid found in the cellular membranes of the coronary artery. This increases the sphingomyelin content in the cell membrane, which in turn enhances the interaction between the membrane and ionic calcium (Ca(2+)), thereby increasing the risk of arterial calcification. Patients undergoing bypass surgery had greater concentrations of oxysterols in their plasma than cardiac catheterized controls with no stenosis, and had five times more sphingomyelin in their arteries than in the artery of the placenta of a newborn. The oxysterols found in the plasma of these patients were also found in the plasma of rabbits that had been fed oxidized cholesterol and in frying fats and powdered egg yolk intended for human consumption. Together these findings suggest that oxysterols found in the diet are absorbed and contribute to arterial calcification. Oxidized low-density lipoprotein (OxLDL) further contributes to heart disease by increasing the synthesis of thromboxane in platelets, which increases blood clotting. Cigarette smoke and trans fatty acids, found in partially hydrogenated soybean oil, both inhibit the synthesis of prostacyclin, which inhibits blood clotting. By increasing the ratio of thromboxane to prostacyclin, these factors interact to interrupt blood flow, thereby contributing to heart attack and sudden death. Levels of oxysterols and OxLDL increase primarily as a result of three diet or lifestyle factors: the consumption of oxysterols from commercially fried foods such as fried chicken, fish, and french fries; oxidation of cholesterol in vivo driven by consumption of excess polyunsaturated fatty acids from vegetable oils; and cigarette smoking. Along with the consumption of trans fatty acids from partially hydrogenated vegetable oil, these diet and lifestyle factors likely underlie the persistent national burden of heart disease.
Nutr Metab Cardiovasc Dis. 2013 Oct 7.
Ceramides are associated with inflammatory processes in human mediastinal adipose tissue.
Atherosclerosis Research Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.
BACKGROUND AND AIM: Ceramides are poorly characterized in human adipose tissue. The aim of this study was to investigate concentrations of different ceramide species in human subcutaneous and visceral adipose tissue depots and to determine associations between ceramides and global gene expression profiles.
METHODS AND RESULTS: Concentrations of six ceramide species were determined in plasma and in subcutaneous and mediastinal adipose tissue from 10 overweight subjects (BMI 29.4 ± 4.9 kg/m2). In the adipose tissue biopsies gene expression arrays were performed and relationships between ceramides and gene expression analyzed. Immunostaining of the two adipose tissue depots was performed in an independent group of 10 patients. Mediastinal adipose tissue contained significantly higher concentrations (p < 0.05) of all six ceramide species than the subcutaneous depot. Of the six ceramides in plasma, concentrations of only two (Cer d18:1/18:0 and Cer d18:1/22:0) correlated significantly (p < 0.05) with the corresponding species in mediastinal adipose tissue, but there were no significant correlations between ceramides in plasma and subcutaneous adipose tissue. Multivariate analysis identified significant correlations between the total ceramide concentration and global gene expression within mediastinal, but not subcutaneous adipose tissue, according to cross-validation. Gene ontology analysis of genes related to ceramides in the mediastinal depot revealed that genes positively correlated with ceramides were associated mainly with immune and inflammatory categories, while genes negatively correlated with ceramides were associated mainly with lipid and carbohydrate metabolism.
CONCLUSIONS: Ceramides in human mediastinal adipose tissue may be involved in inflammation and lipid and carbohydrate metabolism
Adv Exp Med Biol. 2011;721:57-66.
Blood sphingolipids in homeostasis and pathobiology.
Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, South Carolina, USA.
ABSTRACT: Sphingolipids have emerged as key signaling molecules involved in the regulation of a variety of cellular functions including cell growth and differentiation, proliferation and apoptotic cell death. Sphingolipids in blood constitute part of the circulating lipoprotein particles (HDL, LDL and VLDL), carried by serum albumin and also present in blood cells and platelets. Recent lipidomic and proteomic studies of plasma lipoproteins have provided intriguing data concerning the protein and lipid composition of lipoproteins in the context of disease. Sphingolipids have been implicated in several diseases such as cancer, obesity, atherosclerosis and sphingolipidoses; however, efforts addressing blood sphingolipidomics are still limited. The development of methods to determine levels of circulating bioactive sphingolipids in humans and validation of these methods to be a routine clinical laboratory test could be a pioneering approach to diagnose disease in the population. This approach would probably evolve to be analogous in implication to determining “good” and “bad” cholesterol and triglyceride levels in lipoprotein classes.
Circ Cardiovasc Genet. 2011 Jun;4(3):232-42.
Comparative lipidomics profiling of human atherosclerotic plaques.
British Heart Foundation Centre, King’s College, London, UK.
BACKGROUND: We sought to perform a systematic lipid analysis of atherosclerotic plaques using emerging mass spectrometry techniques.
METHODS AND RESULTS: A chip-based robotic nanoelectrospray platform interfaced to a triple quadrupole mass spectrometer was adapted to analyze lipids in tissue sections and extracts from human endarterectomy specimens by shotgun lipidomics. Eighteen scans for different lipid classes plus additional scans for fatty acids resulted in the detection of 150 lipid species from 9 different classes of which 24 were detected in endarterectomies only. Further analyses focused on plaques from symptomatic and asymptomatic patients and stable versus unstable regions within the same lesion. Polyunsaturated cholesteryl esters with long-chain fatty acids and certain sphingomyelin species showed the greatest relative enrichment in plaques compared to plasma and formed part of a lipid signature for vulnerable and stable plaque areas in a systems-wide network analysis. In principal component analyses, the combination of lipid species across different classes provided a better separation of stable and unstable areas than individual lipid classes.
CONCLUSIONS: This comprehensive analysis of plaque lipids demonstrates the potential of lipidomics for unraveling the lipid heterogeneity within atherosclerotic lesions.
Membr Biol. 2011 Nov;244(2):97-103.
Influence of phospholipid species on membrane fluidity: a meta-analysis for a novel phospholipid fluidity index.
Centre for Muscle Metabolism and Biophysics, Department of Community Health Sciences, Brock University, St. Catharines, ON, Canada.
ABSTRACT: Generalized membrane lipid composition determinants of fluidity have been widely investigated, including phospholipid/cholesterol ratio and unsaturation index. Individual phospholipids differ in their physical characteristics, including their interaction with cholesterol and level of unsaturation, emphasizing the importance of examining their individual influence on membrane fluidity. Thus, the purpose of this study was to examine the dominant phospholipids of biological membranes (phosphatidylcholine, PC; phosphatidylethanolamine, PE; sphingomyelin, SM) through a meta-analysis to assess the validity of an inclusive phospholipid fluidity index (PFI = PC/(PE + SM)) as a determinant for membrane fluidity (expressed as polarization of fluorescent probe 1,6 diphenyl-1,3,5-hexatriene) in comparison to previous phospholipid ratios (PC/PE and PC/SM). The results demonstrate that all indices significantly predicted membrane fluidity at 25°C (based on 10-13 data points). In contrast, only PFI approached significance when predicting membrane fluidity at 37°C (P = 0.10 based on five points). As a result, PFI appears to be the only phospholipid index close to significantly predicting membrane fluidity at mammalian physiological temperature. Because this meta-analysis only assessed studies using mammalian membranes, future work should experimentally assess the validity of the PFI utilizing membranes from mammals and a variety of other species and tissues at their respective physiological temperatures.
Lipids Health Dis. 2011 Jan 17;10:7.
Adenovirus-mediated sphingomyelin synthase 2 increases atherosclerotic lesions in ApoE KO mice.
School of Pharmacy, Fudan University, Shanghai, China.
BACKGROUND: Sphingomyelin synthase 2 (SMS2) contributes to de novo sphingomyelin (SM) biosynthesis. Its activity is related to SM levels in the plasma and the cell membrane. In this study, we investigated the possibility of a direct relationship between SMS and atherosclerosis.
METHODS: The Adenovirus containing SMS2 gene was given into 10-week ApoE KO C57BL/6J mice by femoral intravenous injection. In the control group, the Adenovirus containing GFP was given. To confirm this model, we took both mRNA level examination (RT-PCR) and protein level examination (SMS activity assay).
RESULT: We generated recombinant adenovirus vectors containing either human SMS2 cDNA (AdV-SMS2) or GFP cDNA (AdV-GFP). On day six after intravenous infusion of 2 × 10(11) particle numbers into ten-week-old apoE KO mice, AdV-SMS2 treatment significantly increased liver SMS2 mRNA levels and SMS activity (by 2.7-fold, 2.3-fold, p < 0.001, respectively), compared to AdV-GFP treated mice. Moreover, plasma total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), triglyceride (TG), and sphingomyelin (SM) levels were significantly increased by 39% (p < 0.05), 42% (p < 0.05), 68% (p < 0.001), and 45% (p < 0.05), respectively. Plasma high-density lipoprotein cholesterol (HDL-C), phosphatidylcholine (PC), and PC/SM ratio were decreased by 42% (p < 0.05), 18% (p < 0.05), and 45% (p < 0.05), respectively. On day 30, the atherosclerotic lesions on the aortic arch of AdV-SMS2 treated mice were increased, and the lesion areas on the whole aorta and in the aortic root were significantly increased (p < 0.001). Furthermore, the collagen content in the aorta root was significantly decreased (p < 0.01).
CONCLUSIONS: Our results present direct morphological evidence for the pro-atherogenic capabilities of SMS2. SMS2 could be a potential target for treating atherosclerosis.
Am J Physiol Heart Circ Physiol. 2010 Dec;299(6):H2046-55.
Short-term magnesium deficiency upregulates sphingomyelin synthase and p53 in cardiovascular tissues and cells: relevance to the de novo synthesis of ceramide.
Department of Physiology and Pharmacology, State University of New York, Brooklyn, New York, USA.
ABSTRACT: The present study tested the hypotheses that 1) short-term dietary deficiency of magnesium (21 days) in rats would result in the up-regulation of sphingomyelin synthase (SMS) and p53 in cardiac and vascular (aortic) smooth muscles, 2) low levels of Mg(2+) added to drinking water would either prevent or greatly reduce the up-regulation of both SMS and p53, 3) exposure of primary cultured vascular smooth muscle cells (VSMCs) to low extracellular Mg(2+) concentration ([Mg(2)](o)) would lead to the de novo synthesis of ceramide, 4) inhibition of either SMS or p53 in primary culture VSMCs exposed to low [Mg(2+)](o) would lead to reductions in the levels of de novo ceramide synthesis, and 5) inhibition of sphingomyelin palmitoyl-CoA transferase (SPT) or ceramide synthase (CS) in primary cultured VSMCs exposed to low [Mg(2+)](o) would lead to a reduction in the levels of de novo ceramide synthesis. The data indicated that short-term magnesium deficiency (10% normal dietary intake) resulted in the upregulation of SMS and p53 in both ventricular and aortic smooth muscles; even very low levels of water-borne Mg(2+) (e.g., 15 mg·l(-1)·day(-1)) either prevented or ameliorated the upregulation in SMS and p53. Our experiments also showed that VSMCs exposed to low [Mg(2+)](o) resulted in the de novo synthesis of ceramide; the lower the [Mg(2+)](o), the greater the synthesis of ceramide. In addition, the data indicated that inhibition of either SMS, p53, SPT, or CS in VSMCs exposed to low [Mg(2+)](o) resulted in marked reductions in the de novo synthesis of ceramide.
Arterioscler Thromb Vasc Biol. 2010 Nov;30(11):2114-20
Selective reduction in the sphingomyelin content of atherogenic lipoproteins inhibits their retention in murine aortas and the subsequent development of atherosclerosis.
Department of Cardiology, Renmin Hospotal, Wuhan University, Wuhan, China.
OBJECTIVE: We used the sphingomyelin (SM) synthase 2 (Sms2) gene knockout (KO) approach to test our hypothesis that selectively decreasing plasma lipoprotein SM can play an important role in preventing atherosclerosis.
METHODS AND RESULTS: The sphingolipid de novo synthesis pathway is considered a promising target for pharmacological intervention in atherosclerosis. However, its potential is hampered because the substance’s atherogenic mechanism is not completely understood. We prepared Sms2 and apolipoprotein E (Apoe) double-KO mice. They showed a significant decrease in plasma lipoprotein SM levels (35%, P<0.01) and a significant increase in ceramide and dihydroceramide levels (87.5% and 27%, respectively; P<0.01) but no significant changes in other tested sphingolipids, cholesterol, and triglyceride. Non-high-density lipoproteins from the double-KO mice showed a reduction of SM, but not cholesterol, and displayed less tendency toward aortic sphingomyelinase-mediated lipoprotein aggregation in vitro and retention in aortas in vivo when compared with controls. More important, at the age of 19 weeks, Sms2 KO/Apoe KO mice showed a significant reduction in atherosclerotic lesions of the aortic arch and root (52%, P<0.01) compared with controls. The Sms2 KO/Apoe KO brachiocephalic artery contained significantly less SM, ceramide, free cholesterol, and cholesteryl ester (35%, 32%, 58%, and 60%, respectively; P<0.01) than that of the Apoe KO brachiocephalic artery.
CONCLUSIONS: Decreasing plasma SM levels through decreasing SMS2 activity could become a promising treatment for atherosclerosis.
Circ Res. 2009 Jul 31;105(3):295-303.
Macrophage sphingomyelin synthase 2 deficiency decreases atherosclerosis in mice.
Department of Cell Biology, State University of New York Downstate Medical Center, Brooklyn, NY 11203, USA.
RATIONALE: Sphingomyelin synthase (SMS)2 contributes to de novo sphingomyelin (SM)
biosynthesis and plasma membrane SM levels. SMS2 deficiency in macrophages diminishes nuclear factor kappaB and mitogen-activated protein kinase activation induced by inflammatory stimuli.
OBJECTIVE: The effects of SMS2 deficiency on the development of atherosclerosis are investigated.
METHODS AND RESULTS: We measured cholesterol efflux from macrophages of wild-type (WT) and SMS2 knockout (KO) mice. We transplanted SMS2 KO mouse bone marrow into low-density lipoprotein (LDL) receptor (LDLr) knockout mice (SMS2(-/-)–>LDLr(-/-)), creating a mouse model of SMS2 deficiency in the macrophages. We found that SMS2 deficiency caused significant induction of cholesterol efflux in vitro and in vivo. Moreover, we found that SMS2 KO mice had less interleukin-6 and tumor necrosis factor alpha in the circulation before and after endotoxin stimulation, compared with controls. More importantly, after 3 months on a western-type diet, SMS2(-/-)–>LDLr(-/-) mice showed decreased atherosclerotic lesions in the aortic arch, root (57%, P<0.001), and the entire aorta (42%, P<0.01), compared with WT–>LDLr(-/-) mice. Analysis of plaque morphology revealed that SMS2(-/-)–>LDLr(-/-) mice had significantly less necrotic core area (71%, P<0.001), less macrophage content (37%, P<0.01), and more collagen content (35%, P<0.05) in atherosclerotic lesions. We also found that SMS2(-/-)–>LDLr(-/-) mice had significantly lower free cholesterol and cholesteryl ester levels in the brachiocephalic artery than WT–>LDLr(-/-) mice (33 and 52%, P<0.01 and P<0.001, respectively).
CONCLUSIONS: SMS2 deficiency in the macrophages reduces atherosclerosis in mice. Macrophage SMS2 is thus a potential therapeutic target for treatment of this disease.
Life Sci. 2006 Jan 25;78(9):958-63.
27-Hydroxycholesterol causes remodeling in endothelial cell membrane lipid composition comparable to remodeling in the failed vein grafts of CABG patients.
Burnsides Research Laboratory, U of Illinois, 1208 W. Pennsylvania Ave., Urbana IL 61801, USA.
ABSTRACT: Our objective is to determine if vascular remodeling in CABG patients is related to oxysterols, therefore, we compared failed vein grafts from 18 patients, available after a second coronary artery bypass grafting (CABG), with human endothelial cells (ECs). The ECs were cultured in minimum essential medium (MEM) with or without 27-hydroxycholesterol (27OHC), one of the oxysterol products of oxidatively modified low density lipoproteins (ox-LDL), as an agent to alter molecular mechanisms in vascular cells. Significant changes in phospholipid composition, in fatty acid profile and in calcium concentration were found in the failed vein compared to the native saphenous vein from the same (CABG) patient. The failed vein contained significantly less phosphatidylethanolamine, more sphingomyelin, less arachidonic acid, more linoleic acid and more calcium than the native saphenous vein. Comparable changes in phospholipid composition, in fatty acid profile and increased calcium influx were reproduced in ECs cultured in medium containing 27OHC indicating that an oxysterol is an agent that can alter the lipid composition of vascular cell membranes. Our study indicates that a lipid agent, as well as protein agents that have previously been linked to the process of vascular remodeling, may be fundamental to many vascular diseases.
Biochim Biophys Acta. 2005 Jul 15;1735(2):130-4.
The effect of dietary sphingolipids on plasma sphingomyelin metabolism and atherosclerosis.
Department of Anatomy and Cell Biology, SUNY Downstate Medical Center, Brooklyn, NY 11203, USA.
ABSTRACT: Sphingomyelin (SM) plays a very important role in cell membrane formation and plasma lipoprotein metabolism. All these functions may have an impact on atherosclerotic development. To investigate the relationship between SM metabolism and atherosclerosis, we utilized a sphingolipid-rich diet to feed LDL receptor gene knockout (LDLr KO) mice and studied lipid metabolism and atherosclerosis in the mice. After 3 months of a sphingolipid-rich diet, we found a significant increase in SM, cholesterol, and SM/phosphatidylcholine (PC) ratio (50%, P<0.001; 62%, P<0.01; and 45%, P<0.01, respectively), compared to chow fed diet. HDL-lipids were not significantly altered. Non-HDL-SM, non-HDL-C, and non-HDL-SM/non-HDL-PC ratio were significantly increased (115%, P<0.001; 106%, P<0.001; and 106%, P<0.01, respectively). FPLC confirmed the results. SDS-PAGE showed an increase of apoB48 and apoB100, but no changes of apoAI. Moreover, we found that an SM-rich diet significantly increased atherosclerotic lesion area in both root assay and en face assay, compared to chow diet (58,210+/-15,300 microm(2) vs. 9670+/-2370 microm(2), P<0.001; 5.9+/-3.1% vs. 1.1+/-0.9%, P<0.001). These results indicate that the enrichment of sphingolipids in diet has proatherogenic properties.
J Nutr Biochem. 2001 Oct;12(10):602-607.
Changes in the phospholipid composition of the arterial cell can result in severe atherosclerotic lesions.
The Burnsides Research Laboratory, University of Illinois, 61801, Urbana, IL, USA
ABSTRACT: The oxysterol concentration in the plasma and the phospholipid composition of vascular tissue obtained by coronary artery bypass grafting (CABG) were compared with plasma and vascular tissue from age and sex matched controls. The plasma from CABG patients had a higher concentration of oxysterols than was present in the controls. Human endothelial cells were cultured for 72 hours in a medium containing plasma obtained from CABG patients, from controls or from the same controls to which 5 oxysterols were added to make the total oxysterol level equivalent to that in the CABG plasma and then pulsed with calcium (45Ca(2+)) for one hr. A significantly higher influx of 45Ca(2+) was noted in the endothelial cells cultured in the plasma obtained from CABG patients and from the controls with 5 added oxysterols, but not in those cultured without added oxysterols indicating that oxysterols increased calcium influx into endothelial cells. A phospholipid analysis indicated that the arterial tissue from CABG patients had 48.2% sphingomyelin in its phospholipid fraction compared to 10% in arterial tissue from umbilical cords. The saphenous vein obtained during CABG surgery from the same patient had only 24% sphingomyelin in its phospholipid fraction and unlike the coronary arteries had no atherosclerotic lesions. The higher level of oxysterol in the plasma of patients suffering from severe atherosclerosis could increase the concentration of sphingomyelin in the arterial cell membrane and thereby increase calcium influx required for producing the calcific type VII lesions in the coronary arteries.
Arterioscler Thromb Vasc Biol. 2000 Dec;20(12):2614-8.
Plasma sphingomyelin level as a risk factor for coronary artery disease.
Department of Medicine, Columbia University, New York, NY 10032, USA.
ABSTRACT: Only a fraction of the clinical complications of atherosclerosis are explained by known risk factors. Animal studies have shown that plasma sphingomyelin (SM) levels are closely related to the development of atherosclerosis. SM carried into the arterial wall on atherogenic lipoproteins may be locally hydrolyzed by sphingomyelinase, promoting lipoprotein aggregation and macrophage foam cell formation. A novel, high-throughput, enzymatic method to measure plasma SM levels has been developed. Plasma SM levels were related to the presence of coronary artery disease (CAD) in a biethnic angiographic case-control study (279 cases and 277 controls). Plasma SM levels were higher in CAD patients than in control subjects (60+/-29 versus 49+/-21 mg/dL, respectively; P:<0. 0001). Moreover, the ratio of SM to SM+phosphatidylcholine (PC) was also significantly higher in cases than in controls (0.33+/-0.13 versus 0.29+/-0.10, respectively; P:<0.0001). Similar relationships were observed in African Americans and whites. Plasma SM levels showed a significant correlation with remnant cholesterol levels (r=0.51, P:<0.0001). By use of multivariate logistic regression analysis, plasma SM levels and the SM/(SM+PC) ratio were found to have independent predictive value for CAD after adjusting for other risk factors, including remnants. The odds ratio (OR) for CAD was significantly higher for the third and fourth quartiles of plasma SM levels (OR 2.81 [95% CI 1.66 to 4.80] and OR 2.33 [95% CI 1.38 to 3. 92], respectively) as well as the SM/(SM+PC) ratio (OR 1.95 [95% CI 1.10 to 3.45] and OR 2.33 [95% CI 1.34 to 4.05], respectively). The findings indicate that human plasma SM levels are positively and independently related to CAD. Plasma SM levels could be a marker for atherogenic remnant lipoprotein accumulation and may predict lipoprotein susceptibility to arterial wall sphingomyelinase.
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