indian journal of medical research supplement

Indian Journal of Medical Research, Supplement

Subject Area and Category

• Biochemistry, Genetics and Molecular Biology (miscellaneous)
• Medicine (miscellaneous)

Publication type

2004-2005, 2012-2021

Information

How to publish in this journal

[email protected]

The set of journals have been ranked according to their SJR and divided into four equal groups, four quartiles. Q1 (green) comprises the quarter of the journals with the highest values, Q2 (yellow) the second highest values, Q3 (orange) the third highest values and Q4 (red) the lowest values.

The SJR is a size-independent prestige indicator that ranks journals by their 'average prestige per article'. It is based on the idea that 'all citations are not created equal'. SJR is a measure of scientific influence of journals that accounts for both the number of citations received by a journal and the importance or prestige of the journals where such citations come from It measures the scientific influence of the average article in a journal, it expresses how central to the global scientific discussion an average article of the journal is.

Evolution of the number of published documents. All types of documents are considered, including citable and non citable documents.

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Indian Journal of Medical Research, Supplement - Impact Score, Ranking, SJR, h-index, Citescore, Rating, Publisher, ISSN, and Other Important Details

Published By: Indian Council of Medical Research

Abbreviation: Indian J. Med. Res. Suppl.

Impact Score The impact Score or journal impact score (JIS) is equivalent to Impact Factor. The impact factor (IF) or journal impact factor (JIF) of an academic journal is a scientometric index calculated by Clarivate that reflects the yearly mean number of citations of articles published in the last two years in a given journal, as indexed by Clarivate's Web of Science. On the other hand, Impact Score is based on Scopus data.

Important details, about indian journal of medical research, supplement.

Indian Journal of Medical Research, Supplement is a journal published by Indian Council of Medical Research . This journal covers the area[s] related to Biochemistry, Genetics and Molecular Biology (miscellaneous), Medicine (miscellaneous), etc . The coverage history of this journal is as follows: 2004-2005, 2012-2021. The rank of this journal is 26285 . This journal's impact score, h-index, and SJR are 0.00, 23, and 0.103, respectively. The ISSN of this journal is/are as follows: 03679012 . The best quartile of Indian Journal of Medical Research, Supplement is Q4 . This journal has received a total of 0 citations during the last three years (Preceding 2022).

Indian Journal of Medical Research, Supplement Impact Score 2022-2023

The impact score (IS), also denoted as the Journal impact score (JIS), of an academic journal is a measure of the yearly average number of citations to recent articles published in that journal. It is based on Scopus data.

Prediction of Indian Journal of Medical Research, Supplement Impact Score 2023

Impact Score 2022 of Indian Journal of Medical Research, Supplement is 0.00 . If a similar downward trend continues, IS may decrease in 2023 as well.

Impact Score Graph

Check below the impact score trends of indian journal of medical research, supplement. this is based on scopus data., indian journal of medical research, supplement h-index.

The h-index of Indian Journal of Medical Research, Supplement is 23 . By definition of the h-index, this journal has at least 23 published articles with more than 23 citations.

What is h-index?

The h-index (also known as the Hirsch index or Hirsh index) is a scientometric parameter used to evaluate the scientific impact of the publications and journals. It is defined as the maximum value of h such that the given Journal has published at least h papers and each has at least h citations.

Indian Journal of Medical Research, Supplement ISSN

The International Standard Serial Number (ISSN) of Indian Journal of Medical Research, Supplement is/are as follows: 03679012 .

The ISSN is a unique 8-digit identifier for a specific publication like Magazine or Journal. The ISSN is used in the postal system and in the publishing world to identify the articles that are published in journals, magazines, newsletters, etc. This is the number assigned to your article by the publisher, and it is the one you will use to reference your article within the library catalogues.

ISSN code (also called as "ISSN structure" or "ISSN syntax") can be expressed as follows: NNNN-NNNC Here, N is in the set {0,1,2,3...,9}, a digit character, and C is in {0,1,2,3,...,9,X}

Indian Journal of Medical Research, Supplement Ranking and SCImago Journal Rank (SJR)

SCImago Journal Rank is an indicator, which measures the scientific influence of journals. It considers the number of citations received by a journal and the importance of the journals from where these citations come.

Indian Journal of Medical Research, Supplement Publisher

The publisher of Indian Journal of Medical Research, Supplement is Indian Council of Medical Research . The publishing house of this journal is located in the India . Its coverage history is as follows: 2004-2005, 2012-2021 .

Call For Papers (CFPs)

Please check the official website of this journal to find out the complete details and Call For Papers (CFPs).

Abbreviation

The International Organization for Standardization 4 (ISO 4) abbreviation of Indian Journal of Medical Research, Supplement is Indian J. Med. Res. Suppl. . ISO 4 is an international standard which defines a uniform and consistent system for the abbreviation of serial publication titles, which are published regularly. The primary use of ISO 4 is to abbreviate or shorten the names of scientific journals using the technique of List of Title Word Abbreviations (LTWA).

As ISO 4 is an international standard, the abbreviation ('Indian J. Med. Res. Suppl.') can be used for citing, indexing, abstraction, and referencing purposes.

How to publish in Indian Journal of Medical Research, Supplement

If your area of research or discipline is related to Biochemistry, Genetics and Molecular Biology (miscellaneous), Medicine (miscellaneous), etc. , please check the journal's official website to understand the complete publication process.

Acceptance Rate

• Interest/demand of researchers/scientists for publishing in a specific journal/conference.
• The complexity of the peer review process and timeline.
• Time taken from draft submission to final publication.
• Number of submissions received and acceptance slots
• And Many More.

The simplest way to find out the acceptance rate or rejection rate of a Journal/Conference is to check with the journal's/conference's editorial team through emails or through the official website.

Frequently Asked Questions (FAQ)

What is the impact score of indian journal of medical research, supplement.

The latest impact score of Indian Journal of Medical Research, Supplement is 0.00. It is computed in the year 2023.

What is the h-index of Indian Journal of Medical Research, Supplement?

The latest h-index of Indian Journal of Medical Research, Supplement is 23. It is evaluated in the year 2023.

What is the SCImago Journal Rank (SJR) of Indian Journal of Medical Research, Supplement?

The latest SCImago Journal Rank (SJR) of Indian Journal of Medical Research, Supplement is 0.103. It is calculated in the year 2023.

What is the ranking of Indian Journal of Medical Research, Supplement?

The latest ranking of Indian Journal of Medical Research, Supplement is 26285. This ranking is among 27955 Journals, Conferences, and Book Series. It is computed in the year 2023.

Who is the publisher of Indian Journal of Medical Research, Supplement?

Indian Journal of Medical Research, Supplement is published by Indian Council of Medical Research. The publication country of this journal is India.

What is the abbreviation of Indian Journal of Medical Research, Supplement?

This standard abbreviation of Indian Journal of Medical Research, Supplement is Indian J. Med. Res. Suppl..

Is "Indian Journal of Medical Research, Supplement" a Journal, Conference or Book Series?

Indian Journal of Medical Research, Supplement is a journal published by Indian Council of Medical Research.

What is the scope of Indian Journal of Medical Research, Supplement?

• Biochemistry, Genetics and Molecular Biology (miscellaneous)
• Medicine (miscellaneous)

For detailed scope of Indian Journal of Medical Research, Supplement, check the official website of this journal.

What is the ISSN of Indian Journal of Medical Research, Supplement?

The International Standard Serial Number (ISSN) of Indian Journal of Medical Research, Supplement is/are as follows: 03679012.

What is the best quartile for Indian Journal of Medical Research, Supplement?

The best quartile for Indian Journal of Medical Research, Supplement is Q4.

What is the coverage history of Indian Journal of Medical Research, Supplement?

The coverage history of Indian Journal of Medical Research, Supplement is as follows 2004-2005, 2012-2021.

Credits and Sources

• Scimago Journal & Country Rank (SJR), https://www.scimagojr.com/
• Journal Impact Factor, https://clarivate.com/
• Issn.org, https://www.issn.org/
• Scopus, https://www.scopus.com/

Note: The impact score shown here is equivalent to the average number of times documents published in a journal/conference in the past two years have been cited in the current year (i.e., Cites / Doc. (2 years)). It is based on Scopus data and can be a little higher or different compared to the impact factor (IF) produced by Journal Citation Report. Please refer to the Web of Science data source to check the exact journal impact factor ™ (Thomson Reuters) metric.

Impact Score, SJR, h-Index, and Other Important metrics of These Journals, Conferences, and Book Series

Check complete list

Indian Journal of Medical Research, Supplement Impact Score (IS) Trend

Top journals/conferences in biochemistry, genetics and molecular biology (miscellaneous), top journals/conferences in medicine (miscellaneous).

Indian Journal of Medical Research, Supplement Impact Factor & Key Scientometrics

Indian journal of medical research, supplement overview, impact factor.

I. Basic Journal Info

Journal ISSN: 3679012

Publisher: indian council of medical research, history: 2004-2005, 2012-2021, journal hompage: link, how to get published:, research categories, scope/description:.

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II. Science Citation Report (SCR)

Indian journal of medical research, supplement scr impact factor, indian journal of medical research, supplement scr journal ranking, indian journal of medical research, supplement scimago sjr rank.

SCImago Journal Rank (SJR indicator) is a measure of scientific influence of scholarly journals that accounts for both the number of citations received by a journal and the importance or prestige of the journals where such citations come from.

Indian Journal of Medical Research, Supplement Scopus 2-Year Impact Factor Trend

Indian journal of medical research, supplement scopus 3-year impact factor trend, indian journal of medical research, supplement scopus 4-year impact factor trend, indian journal of medical research, supplement impact factor history.

• 2022 Impact Factor 0 0 2.62
• 2021 Impact Factor 0.214 1.977 1.927
• 2020 Impact Factor 3.1 2.854 2.288
• 2019 Impact Factor 1.341 1.136 1.447
• 2018 Impact Factor 1 1.369 1.278
• 2017 Impact Factor 1.753 1.62 1.561
• 2016 Impact Factor 0.721 0.688 0.658
• 2015 Impact Factor 0 0.333 0.333
• 2014 Impact Factor 0.333 NA NA
• 2013 Impact Factor 0.111 NA NA
• 2012 Impact Factor 0 NA NA
• 2011 Impact Factor NA NA NA
• 2010 Impact Factor NA NA NA
• 2009 Impact Factor NA NA NA
• 2008 Impact Factor NA NA NA
• 2007 Impact Factor 0 NA NA
• 2006 Impact Factor 1.068 NA NA
• 2005 Impact Factor 0.828 NA NA
• 2004 Impact Factor 0 NA NA
• 2003 Impact Factor NA NA NA
• 2002 Impact Factor NA NA NA
• 2001 Impact Factor NA NA NA
• 2000 Impact Factor NA NA NA

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Impact factor (IF) is a scientometric factor based on the yearly average number of citations on articles published by a particular journal in the last two years. A journal impact factor is frequently used as a proxy for the relative importance of a journal within its field. Find out more: What is a good impact factor?

III. Other Science Influence Indicators

Any impact factor or scientometric indicator alone will not give you the full picture of a science journal. There are also other factors such as H-Index, Self-Citation Ratio, SJR, SNIP, etc. Researchers may also consider the practical aspect of a journal such as publication fees, acceptance rate, review speed. ( Learn More )

Indian Journal of Medical Research, Supplement H-Index

The h-index is an author-level metric that attempts to measure both the productivity and citation impact of the publications of a scientist or scholar. The index is based on the set of the scientist's most cited papers and the number of citations that they have received in other publications

Indian Journal of Medical Research, Supplement H-Index History

scijournal.org is a platform dedicated to making the search and use of impact factors of science journals easier.

Indian Journal of Medical Research, Supplement

• Scopus journals
• Biochemistry, Genetics and Molecular Biology(all)

The scientific journal Indian Journal of Medical Research, Supplement is included in the Scopus database. Based on 2020, SJR is 0.418. Publisher country is India. The main subject areas of published articles are Biochemistry, Genetics and Molecular Biology(all), Medicine(all).

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• SCOPUS classifier
• 1300 Biochemistry, Genetics and Molecular Biology(all)
• 2700 Medicine(all)

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Vitamin D Supplements in the Indian Market

Department of Pharmacology, Vardhaman Mahavir Medical College and Safdarjung Hospital, New Delhi-110 029, India

Preeta Kaur Chugh

C. d. tripathi.

It is now known that vitamin D deficiency is a worldwide health problem. In our country, as food fortification is lacking, supplementation with pharmaceutical preparations is the only means of treatment of vitamin D deficiency. We aimed to study the composition and availability of various vitamin D preparations in the Indian market, data about which was collected from annual drug compendium. The preparations were assessed for total number, different formulations, constituents and amount of each constituent present in the formulation. Vitamin D3 is available in the form of cholecalciferol, alfacalcidiol and calcitriol as single ingredient products and in combination with calcium and other micronutrients. Most of the supplements contain calcitriol (46.5%) or alfacalcidiol (43%) as tablets (51.1%) and capsules (35.2%). Cholecalciferol, the preferred form for prophylaxis and treatment of vitamin D deficient states, constitutes only 10% of the available market preparations. High market sales of calcium supplements containing calcitriol indicate increasing intake of calcitriol rather than cholecalciferol; which could predispose to toxicity. There is a need for marketing and rational prescribing of the appropriate vitamin D supplement in ostensibly healthy Indian population. Implementation of population-based education and intervention programmes with enforcement of strict regulations could generate awareness and curb unsupervised intake of vitamin D containing dietary supplements. This health challenge mandates effective nutritional policies, fortification and supplementation programmes and partnership between government, healthcare and industry to safeguard the health of Indian population at large.

It has been widely accepted that vitamin D deficiency (VDD) is a global health problem that impacts not only musculoskeletal health but also varied acute and chronic diseases[ 1 ]. Low vitamin D has been associated with an increased risk of diabete smellitus, cardio vascular disease, certain cancers, cognitive decline, autoimmune disorders and pregnancy complications[ 2 ]. It has been estimated that 20 to 80% of US, Canadian and European men and women are vitamin D deficient[ 1 , 3 , 4 ]. In Middle East and Asia, VDD is highly prevalent in both children and adults[ 1 , 2 , 5 ]. Even in India, numerous studies across various regions of the country indicate that approximately 70-90% of apparently healthy population is vitamin D deficient[ 6 , 7 , 8 , 9 ]. Low vitamin D status is prevalent irrespective of age, sex, profession, rural/urban settings or regional distribution[ 10 , 11 ]( Table 1 ).

VITAMIN D SERUM LEVELS IN DIFFERENT POPULATION GROUPS ACROSS INDIA

The major source of vitamin D is exposure to sunlight. It has been presumed that Indians are vitamin D sufficient due to adequatesunshine throughout the year[ 6 ]. However, reduced cutaneous synthesis of vitamin D could be attributed to limited UV exposure owing to increased skin pigmentation, topical application of sunscreen, certain sociocultural practice sandurban lifestyle[ 6 ]. Secondary sources includedietary intake of foods naturally richin vitamin D such as salmon, codliveroil, sundried mushrooms or vitamin D fortified foods[ 2 , 28 ]. In our country, availability, acceptability and cost of these dietary products limits their widespread use by the general population. This complex interplay between lack of adequate sun exposure, deficient intake and effective food fortification strategies makes Asian Indian population particularly susceptible to vitamin D insufficiency/deficiency. Thus, vitamin D supplementation in the form of pharmaceutical preparations is one of the most effective ways to prevent and treat VDD in high-risk groups[ 29 ]. We, therefore undertook a study to ascertain that availability and composition of various pharmaceutical preparations of vitamin D in the Indian market.

MATERIALS AND METHODS

This study was conducted to determine the number and composition of the various vitamin D pharmaceutical preparations. Data for the study was collected from an annual Drug Compendium entitled The Drug Today 2013 (October–December 2013 issue) and product labels. The preparations were assessed for total number, different formulations, constituents and amount of each constituent present in the formulation.

Analysis of various vitamin D preparations:

A total of 258 vitamin D formulations are available in the Indian market. Vitamin D is commonly available in two forms: Vitamin D2 (ergocalciferol) and vitamin D3 (cholecalciferol). Only two preparations contain vitamin D2 (ergocalciferol). More than 99.9% of the preparations contain vitamin D3 in the form of alfacalcidiol (25 hydroxycholecalciferol), calcitriol (1,25 dihydroxycholecalciferol) or cholecalciferol (inactive vitamin D). Most of the preparations contain calcitriol ( n =120,46.5%) or alfacacidiol ( n =111;43.02%). Approximately 10% of preparations contain cholecalciferol ( n =27, 10.5%)( fig. 1 , Tables ​ Tables2 2 and ​ and3 3 ).

Various vitamin D preparations available in Indian market.

All the available cholecalciferol preparations (CC) (10.5%) contain only vitamin D3. 39 % of calcitriol preparations contain vitamin D3 in combination with minerals /vitamins (C-MV) and 7.5% contain vitamin D3 alone (C). 23.22% of alfacalcidiol preparations contain vitamin D3 in combination with minerals /vitamins (A-MV) and 19.8% contain vitamin D3 alone (A)

VITAMIN D3 PREPARATIONS AVAILABLE IN THE MARKET

COMMONLY AVAILABLE VITAMIN D BRANDED PREPARATIONS IN THE MARKET

Different formulations of vitamin D:

The most common formulation for oral administration is in the form of tablets ( n =132, 51.1%) and capsules ( n =91, 35.2%). Though alfacalcidiol and calcitriol are commonly available as tablets and capsules; cholecalciferol is in the form of granules in sachets ( n =17, 62.9%). Other dosage forms include syrups and softgel capsules. Though oral administration in the form of drops is commonly recommended for infants and children, adolescents and adults are usually prescribed tablets, capsules or granules for supplementation. While all cholecalciferol preparations are available as a single constituent; more than 75% of alfacalcidiol preparations also contain calcium ( n =85, 76.5%). Majority of calcitriol preparations are combined with zinc or zinc sulphate ( n =87, 72.5%). Vitamin D preparations also contain various other minerals/vitamins such as magnesium, cupric, boron, methylcobalamin, vitamin E, vitamin K, vitamin C, pyridoxine, folic acid, beta-carotene, glutamic acid, manganese, omega 3 and docosapentaenoic acid. Tablets and capsules contain 10 IU (0.25 μg) -10000 IU (25 mg) of vitamin D and are usually administered on a daily basis. Sachets of cholecalciferol containing granules of vitamin D amount to 60,000 IU of vitamin D are administered weekly. Vitamin D2 (doxercalciferol) preparation is available in tablet form (two formulations) containing 20 IU (0.5 μg) and 100 IU (2.5 μg) respectively ( Table 3 ).

Cost analysis:

Cost analysis reveals that tablets/capsules of alfacalcidiol (equivalent to 10 IU of vitamin D) and calcitriol (0.25 μg) commonly costs Indian National Rupees (INR) 5.5 and INR 7, respectively ( Table 4 ). Whereas, cholecalciferol granules (equivalent to 60,000 IU) costs INR 20. The common treatment regime for VDD is 60000 IU weekly for eight weeks, which costs approximately INR 160. Furthermore, vitamin D given monthly as maintenance therapy for a year would cost INR 240.

THE COST (IN INDIAN NATIONAL RUPEES) OF VARIOUS DOSAGE FORMS OF VITAMIN D3 PREPARATIONS

Vitamin D deficient state has become one of the most prevalent and underdiagnosed medical conditions in the world[ 1 , 30 ]. Recent evidence suggests that lack of adequate sun exposure is the most important factor for this global pandemic as very few foods naturally contain vitamin D (wild caught salmon and UV exposed mushrooms)[ 2 ]. Analysis in children and adults indicate that dietary sources are grossly inadequate in providing the Recommended Dietary Allowances (RDA) for vitamin D. In our population, cutaneous production of vitamin D is further limited by increased melanin content of skin or sun avoidance by use of sunscreens, extensive clothing cover due to sociocultural practices or staying indoors for most of the day[ 6 ]. Deficient vitamin D status can be corrected either by vitamin D fortification (addition of micronutrients to processed foods) or supplementation (the provision of relatively large doses of micronutrients, usually in form of pills, capsules or syrup).Vitamin D fortification is an effective and passive way to increase vitamin D intake in both general population and vulnerable groups[ 31 , 32 , 33 ]. However, it mandates political commitment and involvement of various ministries (health, agriculture and social welfare) to develop nationwide strategies for a better vitamin D status in the population. In our country, where vitamin D fortification initiative is lacking, supplementation is the only alternative[ 34 ].

In our analysis, we found that multiple supplements of vitamin D are available. The two common forms are vitamin D3 (alfacalcidiol, cholecalciferol and calcitriol) and vitamin D2 (ergocalciferol). Evidence suggests that cholecalciferol is superior to ergocalciferol in terms of potency, elevating and sustaining 25 (OH) D concentrations and maintaining the storage form of vitamin D[ 35 , 36 ]. In our analysis, we were not able to ascertain the cause of lack of availability of vitamin D2 preparations in the Indian market. Majority of preparations available in the market contain vitamin D3 (99.9%). About half of the preparations (46.5%) contain calcitriol in the form of tablets or capsules of 0.25 mcg. Calcitriol has a rapid onset of action with short half-life of 6 h. It is most useful in chronic kidney disease and type I and type II vitamin D deficient rickets (VDDR) with decreased synthesis of calcitriol. Though calcitriol is the most commonly available form, it is not the preferred agent for treatment of nutritional deficiency or stoss therapy (single large oral/ intramuscular therapy). It is associated with a high incidence of hypercalcemia and requires serum calcium monitoring. Furthermore, when calcitriol is used as a supplement, 25(OH) D levels do not indicate clinical vitamin D status. Calcitriol does not build up stores and is an expensive preparation[ 37 ]. Around 43% of the preparations contained alfacalcidiol (25 dihydroxy cholecalciferol). It is most commonly available as tablets or capsules of 10 IU, usually in combination with calcium (76.5% of alfacalcidiol preparations). Alfacalcidiol has a rapid onset of action with a half life of 2-3 weeks. It does not require hepatic 25-hydroxylation, and is therefore most useful in patients with liver disease. Approximately 10% of vitamin D3 preparations are available as cholecalciferol. It is the inactive, unhydroxylated form of vitamin D3, synthesized in skin from 7 dehydrocholesterol. It has a slow onset of action with a half-life of 12-30 days. Thus, it is the preferred form for prophylaxis or treatment of vitamin D deficient states[ 37 ].

Vitamin D can be administered daily, weekly, monthly, or every 4 months to sustain an adequate serum 25 (OH) D concentrations[ 38 , 39 , 40 ]. A high bolus dose of vitamin D (up to 300,000 IU) can be used initially in persons with extreme VDD. Repeated boluses of high-dose vitamin D at 6- to 12-month intervals have been used in a nursing home setting, but a steady-state serum 25(OH) D concentration is likely to be maintained by more frequent, lower doses of vitamin D. An effective strategy to treat vitamin D deficient state in children and adults is to administer 50,000 IU of vitamin D3 once a week for 6-8 weeks respectively<<sup> 43 . To prevent recurrence, administration of 600 to 1000 IU/day is effective[ 43 ]. In our country, most market preparations contain 60, 000 IU, and are usually recommended for 6 to 8 weeks for obtaining adequate serum 25 (OH) D concentrations. A monthly maintenance therapy is usually required and should be continued for over one year[ 44 ]. Another study suggested that a single high dose of 120,000-180,000 IU of oral cholecalciferol was adequate to elevate 25(OH) D out of the deficiency range. However, maintenance dose is required for sustaining the desired concentration of 25(OH) D[ 44 , 45 ]. Our analysis suggests that this treatment regime would initially cost approx. INR 160 and a maintenance therapy for a year would cost INR 240. However, the treatment costs are usually higher as calcium supplements are coadministered with vitamin D therapy

Vitamin D supplementation varies with the RDA, tolerable upper levels in different age groups and in certain circumstances[ 46 ]. The Institute of Medicine (IOM), USA guidelines suggest a vitamin D sufficient level of 20 ng/ml to optimize bone health[ 47 ]. In contrast, US Endocrine Society recommends that serum 25 (OH) D levels of 30 ng/ml (vitamin D sufficiency) should be attained for children and adults to optimize the probability of good health and avoid other risk associated with vitamin D deficient status ( Table 5 ). Furthermore, it is now acknowledged that previously recommended vitamin D intake of 200 IU/day in the American recommended intakes or 400 IU/day in the WHO report are grossly inadequate[ 46 ]. Thus, RDA of 600-800 IU is recommended to maintain adequate levels of vitamin D[ 46 ]. In our country, Indian Council of Medical Research (ICMR) recommends a daily supplement of 400 IU/day of vitamin D for Indians under situations of minimal exposure to sunlight[ 34 ]. However, in light of recent evidence, there is a need to update these guidelines regarding vitamin D intake and supplementation in adults, vulnerable population and susceptible groups[ 48 , 49 , 50 ]. It is now recognized that vitamin D is not as toxic as once thought to be. IOM recommends that up to 4,000 IUs of vitamin D/day is safe for most children and adults. Studies in various populations have shown that adults can tolerate 10,000 IU of vitamin D/day for at least five months without altering their serum calcium or urinary calcium output[ 50 ]. However, in rare cases, vitamin D toxicity can cause hypercalcemia, hyperphosphatemia, nephrocalcinosis, and soft tissue calcification, thus contributing to high risk of mortality[ 51 ].

VITAMIN D STATUS IN RELATION TO 25-HYDROXY VITAMIN D LEVELS

Studies indicate general and widespread use of dietary supplements across populations[ 52 , 53 ]. Though these supplements often are used with the intention of attaining health benefits by preventing chronic diseases, cumulative effects of widespread supplement use, together with food fortification, have raised concern regarding exceeding upper recommended levels and, thus, long-term safety[ 53 ]. In case of vitamin D, unsupervised intake of alfacalcidiol and calcitriol, which are not recommended for vitamin D deficient states, could result in adverse effects/toxicity[ 54 ]. Thus, it is recommended that supplements should only be used with strong medically based cause, such as symptomatic nutrient deficiency disease[ 53 ]. 'Blanket prescription' of these supplements in all patients for prolonged use should be stopped. Physicians need to evaluate the patient's dietary nutrient consumption, intake of any other multivitamin supplement, potential interactions and prescribe them only on an individual basis

Widespread VDD in the Indian population is a cause for grave concern. Adequate measures are imperative to prevent VDD at the outset. There is a need for educating the masses about sensible sun exposure for vitamin D synthesis and dietary intake of vitamin D rich foods. Fortification of commonly available foods could prevent vitamin D insufficiency in our large population. There is an urgent need to prioritize development of national level programs to provide regulated vitamin D fortified foods at affordable prices for Indian population at large. As far as vitamin D supplements are concerned, their easy availability and chronic self-administration mandates awareness on the part of the consumer, pharmacist, chemists, physicians and regulatory bodies to prevent misuse and serious harm. As evident by high market sales, high intake of calcitriol in the form of dietary calcium supplement in the general population could result in serious hypercalcemia, calcium stones and metastatic calcification. The prescribing physicians need to be aware of this potential risk and should prescribe supplements only on an individual basis for requisite duration. These supplements should be adequately labeled indicating the amount of each constituent with special instructions/precautions/warnings, if any. Stringent regulations are required to keep a check on their marketing and availability. Adequate legal actions are required for pharmaceutical companies/drug firms not adhering to regulatory provisions.

Financial support and sponsorship:

Conflicts of interest:.

There are no conflicts of interest.

Lhamo, et al .: Vitamin D Supplements

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• Volume 3, Issue 1
• Regular use of fish oil supplements and course of cardiovascular diseases: prospective cohort study
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• Ge Chen 1 ,
• Zhengmin (Min) Qian 2 ,
• Junguo Zhang 1 ,
• Shiyu Zhang 1 ,
• http://orcid.org/0000-0002-7003-6565 Zilong Zhang 1 ,
• Michael G Vaughn 3 ,
• Hannah E Aaron 2 ,
• Chuangshi Wang 4 ,
• Gregory YH Lip 5 , 6 and
• http://orcid.org/0000-0002-3643-9408 Hualiang Lin 1
• 1 Department of Epidemiology , Sun Yat-Sen University , Guangzhou , China
• 2 Department of Epidemiology and Biostatistics, College for Public Health and Social Justice , Saint Louis University , Saint Louis , Missouri , USA
• 3 School of Social Work, College for Public Health and Social Justice , Saint Louis University , Saint Louis , Missouri , USA
• 4 Medical Research and Biometrics Centre , Fuwai Hospital, National Centre for Cardiovascular Diseases, Peking Union Medical College , Beijing , China
• 5 Liverpool Centre for Cardiovascular Science , University of Liverpool and Liverpool Heart and Chest Hospital , Liverpool , UK
• 6 Department of Clinical Medicine , Aalborg University , Aalborg , Denmark
• Correspondence to Dr Hualiang Lin, Department of Epidemiology, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China; linhualiang{at}mail.sysu.edu.cn

Objective To examine the effects of fish oil supplements on the clinical course of cardiovascular disease, from a healthy state to atrial fibrillation, major adverse cardiovascular events, and subsequently death.

Design Prospective cohort study.

Setting UK Biobank study, 1 January 2006 to 31 December 2010, with follow-up to 31 March 2021 (median follow-up 11.9 years).

Participants 415 737 participants, aged 40-69 years, enrolled in the UK Biobank study.

Main outcome measures Incident cases of atrial fibrillation, major adverse cardiovascular events, and death, identified by linkage to hospital inpatient records and death registries. Role of fish oil supplements in different progressive stages of cardiovascular diseases, from healthy status (primary stage), to atrial fibrillation (secondary stage), major adverse cardiovascular events (tertiary stage), and death (end stage).

Results Among 415 737 participants free of cardiovascular diseases, 18 367 patients with incident atrial fibrillation, 22 636 with major adverse cardiovascular events, and 22 140 deaths during follow-up were identified. Regular use of fish oil supplements had different roles in the transitions from healthy status to atrial fibrillation, to major adverse cardiovascular events, and then to death. For people without cardiovascular disease, hazard ratios were 1.13 (95% confidence interval 1.10 to 1.17) for the transition from healthy status to atrial fibrillation and 1.05 (1.00 to 1.11) from healthy status to stroke. For participants with a diagnosis of a known cardiovascular disease, regular use of fish oil supplements was beneficial for transitions from atrial fibrillation to major adverse cardiovascular events (hazard ratio 0.92, 0.87 to 0.98), atrial fibrillation to myocardial infarction (0.85, 0.76 to 0.96), and heart failure to death (0.91, 0.84 to 0.99).

Conclusions Regular use of fish oil supplements might be a risk factor for atrial fibrillation and stroke among the general population but could be beneficial for progression of cardiovascular disease from atrial fibrillation to major adverse cardiovascular events, and from atrial fibrillation to death. Further studies are needed to determine the precise mechanisms for the development and prognosis of cardiovascular disease events with regular use of fish oil supplements.

• Health policy
• Nutritional sciences
• Public health

Data availability statement

Data are available upon reasonable request. UK Biobank is an open access resource. Bona fide researchers can apply to use the UK Biobank dataset by registering and applying at http://ukbiobank.ac.uk/register-apply/ .

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:  https://creativecommons.org/licenses/by/4.0/ .

https://doi.org/10.1136/bmjmed-2022-000451

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WHAT IS ALREADY KNOWN ON THIS TOPIC

Findings of the effects of omega 3 fatty acids or fish oil on the risk of cardiovascular disease are controversial

Most previous studies focused on one health outcome and did not characterise specific cardiovascular disease outcomes (eg, atrial fibrillation, myocardial infarction, stroke, heart failure, and major adverse cardiovascular events)

Whether fish oil could differentially affect the dynamic course of cardiovascular diseases, from atrial fibrillation to major adverse cardiovascular events, to other specific cardiovascular disease outcomes, or even to death, is unclear

WHAT THIS STUDY ADDS

In people with no known cardiovascular disease, regular use of fish oil supplements was associated with an increased relative risk of atrial fibrillation and stroke

In people with known cardiovascular disease, the beneficial effects of fish oil supplements were seen on transitions from atrial fibrillation to major adverse cardiovascular events, atrial fibrillation to myocardial infarction, and heart failure to death

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE, OR POLICY

Regular use of fish oil supplements might have different roles in the progression of cardiovascular disease

Further studies are needed to determine the precise mechanisms for the development and prognosis of cardiovascular disease events with regular use of fish oil supplements

Introduction

Cardiovascular disease is the leading cause of death worldwide, accounting for about one sixth of overall mortality in the UK. 1 2 Fish oil, a rich source of omega 3 fatty acids, containing eicosapentaenoic acid and docosahexaenoic acid, has been recommended as a dietary measure to prevent cardiovascular disease. 3 The UK National Institute for Health and Care Excellence recommends that people with or at high risk of cardiovascular disease consume at least one portion of oily fish a week, and the use of fish oil supplements has become popular in the UK and other western countries in recent years. 4 5

Although some epidemiological and clinical studies have assessed the effect of omega 3 fatty acids or fish oil on cardiovascular disease and its risk factors, the findings are controversial. The Agency for Healthcare Research and Quality systematically reviewed 37 observational studies and 61 randomised controlled trials, and found evidence indicating the beneficial effects of higher consumption of fish oil supplements on ischaemic stroke, whereas no beneficial effect was found for atrial fibrillation, major adverse cardiovascular events, myocardial infarction, total stroke, or all cause death. 6 In contrast, the Reduction of Cardiovascular Events with Icosapent Ethyl-Intervention Trial (REDUCE-IT) reported a decreased risk of major adverse cardiovascular events with icosapent ethyl in patients with raised levels of triglycerides, regardless of the use of statins. 7 Most of these findings, however, tended to assess the role of fish oil at a certain stage of cardiovascular disease. For example, some studies restricted the study population to people with a specific cardiovascular disease or at a high risk of cardiovascular disease, 8 9 whereas others evaluated databases of generally healthy populations. 10 All of these factors might preclude direct comparison of the effects of omega 3 fatty acids on atrial fibrillation events or on further deterioration of cardiovascular disease. Few studies have fully characterised specific cardiovascular disease outcomes or accounted for differential effects based on the complex disease characteristics of participants. Hence, in this study, we hypothesised that fish oil supplements might have harmful, beneficial, or no effect on different cardiovascular disease events in patients with varying health conditions.

Most previous studies on the association between fish oil and cardiovascular diseases generally focused on one health outcome. Also, no study highlighted the dynamic progressive course of cardiovascular diseases, from healthy status (primary stage), to atrial fibrillation (secondary stage), major adverse cardiovascular events (tertiary stage), and death (end stage). Clarifying this complex pathway in relation to the detailed progression of cardiovascular diseases would provide substantial insights into the prevention or treatment of future disease at critical stages. Whether fish oil could differentially affect the dynamic course of cardiovascular disease (ie, from atrial fibrillation to major adverse cardiovascular events, to other specific cardiovascular disease outcomes, or even to death) is unclear.

To deal with this evidence gap, we conducted a longitudinal cohort study to estimate the associations between fish oil supplements and specific clinical cardiovascular disease outcomes, including atrial fibrillation, major adverse cardiovascular events, and all cause death in people with no known cardiovascular disease or at high risk of cardiovascular disease for the purpose of primary prevention. We also assessed the modifying effects of fish oil supplements on the disease process, from atrial fibrillation to other outcomes, in people with known cardiovascular disease for the purpose of secondary prevention.

The UK Biobank is a community based cohort study with more than half a million UK inhabitants aged 40-69 years at recruitment. 11–13 Participants were invited to participate in this study if they were registered with the NHS and lived within 35 km of one of 22 Biobank assessment centres. Between 1 March 2006 and 31 July 2010, a baseline survey was conducted, based on a touch screen questionnaire and face-to-face interviews, to collect detailed personal, socioeconomic, and lifestyle characteristics, and information on diseases. 11–13

We excluded patients who had a diagnosis of atrial fibrillation (n=8326), heart failure (n=2748), myocardial infarction (n=11 949), stroke (n=7943), or cancer (n=48 624) at baseline; who withdrew from the study during follow-up (n=1299); or who had incomplete or outlier data for the main information (n=11 748). Because we focused only on a specific sequence of progression of cardiovascular disease (ie, from healthy status to atrial fibrillation, to major adverse cardiovascular events, and then to death), we excluded 1983 participants with other transition patterns. The remaining 415 737 participants were included in this analysis ( figure 1 ).

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Flowchart of selection of participants in study. The count of diagnosed diseases does not equate to the total number of individuals, because each person could have multiple diagnoses

Determining use of fish oil supplements

Information on regular use of fish oil supplements was collected from a self-reported touchscreen questionnaire during the baseline survey. 14 15 Each participant was asked whether they regularly used any fish oil supplement. Trained staff conducted a verbal interview with participants, asking if they were currently receiving treatments or taking any medicines, including omega 3 or fish oil supplements. Based on this information, we classified participants as regular users of fish oil supplements and non-users.

Follow-up and outcomes

Participants were followed up from the time of recruitment to death, loss to follow-up, or the end date of follow-up (31 March 2021), whichever came first. Incident cases of interest, including atrial fibrillation, heart failure, stroke, and myocardial infarction, were identified by linkage to death registries, primary care records, and hospital inpatient records. 11 Information on deaths was obtained from death registries of the NHS Information Centre, for participants in England and Wales, and from the NHS Central Register Scotland, for participants in Scotland. 11 Outcomes were defined by a three character ICD-10 (international classification of diseases, 10th revision) code. In this study, atrial fibrillation was defined by ICD-10 code I48, and major adverse cardiovascular events was determined by a combination of heart failure (I50, I11.0, I13.0, and I13.2), stroke (I60-I64), and myocardial infarction (I21, I22, I23, I24.1, and I25.2) codes.

We collected baseline data on age (<65 years and ≥65 years), sex (men and women), ethnic group (white and non-white), Townsend deprivation index (with a higher score indicating higher levels of deprivation), smoking status (never, previous, and current smokers), and alcohol consumption (never, previous, and current drinkers). Data for sex were taken from information in UK Biobank rather than from patient reported gender. Baseline dietary data were obtained from a dietary questionnaire completed by the patient or by an interviewer. The questionnaire was established for each nation (ie, England, Scotland, and Wales) to assess an individual's usual food intake (oily fish, non-oily fish, vegetables, fruit, and red meat). Diabetes mellitus was defined by ICD-10 codes E10-E14, self-reported physician's diagnosis, self-reported use of antidiabetic drugs, or haemoglobin A1c level ≥6.5% at baseline. Hypertension was defined by ICD-10 code I10 or I15, self-reported physician's diagnosis, self-reported use of antihypertensive drugs, or measured systolic and diastolic blood pressure ≥130/85 mm Hg at baseline. Information on other comorbidities (obesity (ICD-10 code E66), chronic obstructive pulmonary disease (J44), and chronic renal failure (N18)) was extracted from the first occurrence (UKB category ID 1712). Information on the use of drugs, including antihypertensive drugs, antidiabetic drug, and statins, was extracted from treatment and drug use records. Biochemistry markers were measured immediately at the central laboratory from serum samples collected at baseline. Binge drinking was defined as consumption of ≥6 standard drinks/day for women or ≥8 standard drinks/day for men. Detailed information on alcohol consumption and binge drinking in the UK Biobank was reported previously. 16

Statistical analysis

Characteristics of participants are summarised as number (percentages) for categorical variables and mean (standard deviation (SD)) for continuous variables. Comparisons between regular users of fish oil supplements and non-users were made with the χ 2 test or Student's t test.

We used a multi-state regression model to assess the role of regular use of fish oil supplements in the temporal disease progression from healthy status to atrial fibrillation, to major adverse cardiovascular events, and subsequently to death. The multi-state model is an extension of competing risks survival analysis. 17–19 The model allows simultaneous estimation of the role of risk factors in transitions from a healthy state to atrial fibrillation (transition A), healthy state to major adverse cardiovascular events (transition B), healthy state to death (transition C), atrial fibrillation to major adverse cardiovascular events (transition D), atrial fibrillation to death (transition E), and major adverse cardiovascular events to death (transition F) (transition pattern I, figure 2 ). The focus on these six transitions rather than on all possible health state transitions was preplanned and evidence based. If participants entered different states on the same date, we used the date of the theoretically previous state as the entry date of the latter state minus 0.5 days.

Numbers of participants in transition pattern I, from baseline to atrial fibrillation, major adverse cardiovascular events, and death

We further examined the effects of regular use of fish oil supplements on other pathways. For example, we divided major adverse cardiovascular events into three individual diseases (heart failure, stroke, and myocardial infarction), resulting in three independent pathways (transition patterns II, III, and IV, online supplemental figures S1–S3 ). All models were adjusted for age, sex, ethnic group, Townsend deprivation index, consumption of oily fish, consumption of non-oily fish, smoking status, alcohol consumption, obesity, hypertension, diabetes mellitus, chronic obstructive pulmonary disease, chronic renal failure, and use of statins, antidiabetic drugs, and antihypertensive drugs.

Supplemental material

We conducted several sensitivity analyses for the multi-state analyses of transition pattern A: additionally adjusting for setting (urban and rural), body mass index (underweight, normal, overweight, and obese), and physical activity (low, moderate, and high) in the model; adjusting for binge drinking rather than alcohol consumption; additionally adjusting for other variables of dietary intake (consumption of vegetables, fruit, and red meat); calculating participants' entry date into the previous state with different time intervals (0.5 years, one year, and two years); excluding participants who entered different states on the same date; excluding events occurring in the first two years of follow-up; restricting the follow-up date to 31 March 2020 to evaluate the influence of the covid-19 pandemic; and the use of the inverse probability weighted method to deal with biases between the regular users and non-users of fish oil supplements. Also, we conducted grouped analyses for sex, age group, ethnic group, smoking status, consumption of oily fish, consumption of non-oily fish, hypertension, and drug use, to examine effect modification. The interactions were tested with the likelihood ratio test. All analyses were carried out with R software (version 4.0.3), and the multi-model analysis was performed with the mstate package. A two tailed P value <0.05 was considered significant.

Patient and public involvement

Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research. Participants were involved in developing the ethics and governance framework for UK Biobank and have been engaged in the progress of UK Biobank through follow-up questionnaires and additional assessment visits. UK Biobank keeps participants informed of all research output through the study website ( https://www.ukbiobank.ac.uk/explore-your-participation ), participant events, and newsletters.

A total of 415 737 participants (mean age 55.9 (SD 8.1) years; 55% women), aged 40-69 years, were analysed, and 31.4% (n=1 30 365) of participants reported regular use of fish oil supplements at baseline ( figure 1 ). Table 1 shows the characteristics of regular users (n=130 365) and non-users (n=285 372) of fish oil supplements. In the group of regular users of fish oil supplements, we found higher proportions of elderly people (22.6% v 13.9%), white people (95.1% v 94.2%), and women (57.6% v 53.9%), and higher consumption of alcohol (93.1% v 92.0%), oily fish (22.1% v 15.4%), and non-oily fish (18.0% v 15.4%) than non-users. The Townsend deprivation index (mean −1.5 (SD 3.0) v −1.3 (3.0)) and the proportion of current smokers (8.1% v 11.4%) were lower in regular users of fish oil supplements. Online supplemental table S1 provides more details on patient characteristics and online supplemental table S2 compares the basic characteristics of included and excluded people.

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Baseline characteristics of study participants grouped by use of fish oil supplements

Over a median follow-up time of of 11.9 years, 18 367 participants had atrial fibrillation (transition A) and 17 826 participants had major adverse cardiovascular events (transition B); 14 902 participants died without having atrial fibrillation or major adverse cardiovascular events (transition C). Among patients with incident atrial fibrillation, 4810 developed major adverse cardiovascular events (transition D) and 1653 died (transition E). Among patients with incident major adverse cardiovascular events, 5585 died during follow-up (transition F, figure 2 ). In separate analyses for individual diseases (transition patterns II, III, and IV, online supplemental figures S1–S3 ), in patients with atrial fibrillation, 3085 developed heart failure, 1180 had a stroke, and 1415 had a myocardial infarction. During follow-up, 2436, 2088, and 2098 deaths occurred in patients with heart failure, stroke, and myocardial infarction, respectively.

Multi-state regression results

Table 2 shows the different roles of regular use of fish oil supplements in transitions from healthy status to atrial fibrillation, to major adverse cardiovascular events, and then to death. For individuals in the primary stage (healthy status), we found that the use of fish oil supplements had a harmful effect on the transition from health to atrial fibrillation, with an adjusted hazard ratio of 1.13 (95% CI 1.10 to 1.17, transition A). The hazard ratio for transition B (from health to major adverse cardiovascular events) was 1.00 (95% CI 0.97 to 1.04) and for transition C (from health to death) was 0.98 (0.95 to 1.02).

Hazard ratios (95% confidence intervals) for each transition, for different transition patterns for progressive cardiovascular disease by regular use of fish oil supplements

For individuals in the secondary stage (atrial fibrillation) at the beginning of the study, regular use of fish oil supplements decreased the risk of major adverse cardiovascular events (transition D, hazard ratio 0.92, 95% CI 0.87 to 0.98), and had a borderline protective effect on the transition from atrial fibrillation to death (transition E, 0.91, 0.82 to 1.01). For transition F, from major adverse cardiovascular events to death, after adjusting for covariates, the hazard ratio was 0.99 (0.94 to 1.06, transition pattern I, table 2 ).

We divided major adverse cardiovascular events into three individual diseases (ie, heart failure, stroke, and myocardial infarction) and found that regular use of fish oil supplements was marginally associated with an increased risk of stroke in people with a healthy cardiovascular state (hazard ratio 1.05, 95% CI 1.00 to 1.11), whereas a protective effect was found in transitions from healthy cardiovascular states to heart failure (0.92, 0.86 to 0.98). For patients with atrial fibrillation, we found that the beneficial effects of regular use of fish oil supplements were for transitions from atrial fibrillation to myocardial infarction (0.85, 0.76 to 0.96), and from atrial fibrillation to death (0.88, 0.81 to 0.95) for transition pattern IV. For patients with heart failure, we found a protective effect of regular use of fish oil supplements on the risk of mortality (0.91, 0.84 to 0.99) (transition patterns II, III, and IV, table 2 ).

Stratified and sensitivity analyses

We found that age, sex, smoking, consumption of non-oily fish, prevalent hypertension, and use of statins and antihypertensive drugs modified the associations between regular use of fish oil supplements and the transition from healthy states to atrial fibrillation ( online supplemental figure S4 ). We found that the association between regular use of fish oil supplements and risk of transition from healthy states to major adverse cardiovascular events was greater in women (hazard ratio 1.06, 95% CI 1.00 to 1.11, P value for interaction=0.005) and non-smoking participants (1.06, 1.06 to 1.11, P value for interaction=0.001) ( online supplemental figure S4 ). The protective effect of regular use of fish oil supplements on the transition from healthy states to death was greater in men (hazard ratio 0.93, 95% CI 0.89 to 0.98, P value for interaction=0.003) and older participants (0.91, 0.86 to o 0.96, P value for interaction=0.002) ( online supplemental figures S5 and S6 ). The results were not substantially changed in the sensitivity analyses ( online supplemental table S3 ).

Principal findings

Our study characterised the regular use of fish oil supplements on the progressive course of cardiovascular disease, from a healthy state (primary stage), to atrial fibrillation (secondary stage), major adverse cardiovascular events (tertiary stage), and death (end stage). In this prospective analysis of more than 400 000 UK adults, we found that regular use of fish oil supplements could have a differential role in the progression of cardiovascular disease. For people with a healthy cardiovascular profile, regular use of fish oil supplements, a choice of primary prevention, was associated with an increased risk of atrial fibrillation. For participants with a diagnosis of atrial fibrillation, however, regular use of fish oil supplements, as secondary prevention, had a protective effect or no effect on transitions from atrial fibrillation to major adverse cardiovascular events, atrial fibrillation to death, and major adverse cardiovascular events to death. When we divided major adverse cardiovascular events into three individual diseases (ie, heart failure, stroke, and myocardial infarction), we found associations that could suggest a mildly harmful effect between regular use of fish oil supplements and transitions from a healthy cardiovascular state to stroke, whereas potential beneficial associations were found between regular use of fish oil supplements and transitions from atrial fibrillation to myocardial infarction, atrial fibrillation to death, and heart failure to death.

Comparison with other studies

Primary prevention.

The cardiovascular benefits of regular use of fish oil supplements have been examined in numerous studies but the results are controversial. Extending previous reports, our study estimated the associations between regular use of fish oil supplements and specific clinical cardiovascular disease outcomes in people with no known cardiovascular disease. Our findings are in agreement with the results of several previous randomised controlled trials and meta-analyses. The Long-Term Outcomes Study to Assess Statin Residual Risk with Epanova in High Cardiovascular Risk Patients with Hypertriglyceridaemia (STRENGTH) reported that consumption of 4 g/day of marine omega 3 fatty acids was associated with a 69% higher risk of new onset atrial fibrillation in people at high risk of cardiovascular disease. 20 A meta-analysis of seven randomised controlled trials showed that users of marine omega 3 fatty acids supplements had a higher risk of atrial fibrillation events, with a hazard ratio of 1.25 (95% CI 1.07 to 1.46, P=0.013). 21 The Vitamin D and Omega-3 Trial (VITAL Rhythm study), a large trial of omega 3 fatty acids for the primary prevention of cardiovascular disease in adults aged ≥50 years, however, found no effects on incident atrial fibrillation, major adverse cardiovascular events, or cardiovascular disease mortality among those treated with 840 mg/day of marine omega 3 fatty acids compared with placebo. 10 22

One possible explanation for the inconsistent results in these studies is that adverse effects might be related to dose and composition. Higher doses of omega 3 fatty acids used in previous studies might have had an important role in causing an adverse effect on atrial fibrillation. 21 One study found that high concentrations of fish oil altered cell membrane properties and inhibited Na-K-ATPase pump activity, whereas a low concentration of fish oil minimised peroxidation potential and optimised activity. 23 In another study, individuals with atrial fibrillation or flutter had higher percentages of total polyunsaturated fatty acids, and n-3 and n-6 polyunsaturated fatty acids, on red blood cell membranes than healthy controls. 24

In terms of composition of omega 3 fatty acids, a recent meta-analysis showed that eicosapentaenoic acid alone can be more effective at reducing the risk of cardiovascular disease than the combined effect of eicosapentaenoic acid and docosahexaenoic acid. 25 Similar outcomes were reported in the INSPIRE study, which showed that higher levels of docosahexaenoic acid reduced the cardiovascular benefits of eicosapentaenoic acid when given as a combination. 26 Another possible explanation is that age, sex, ethnic group, smoking status, dietary patterns, and use of statins and antidiabetic drugs by participants might modify the effects of regular use of fish oil supplements on cardiovascular disease events. Despite these differences in risk estimates, our findings do not support the use of fish oil or omega 3 fatty acid supplements for the primary prevention of incident atrial fibrillation or other specific clinical cardiovascular disease events in generally healthy individuals. Caution might be warranted when fish oil supplements are used for primary prevention because of the uncertain cardiovascular benefits.

Secondary prevention

Our large scale cohort study assessed the role of regular use of fish oil supplements on the disease process, from atrial fibrillation to more serious cardiovascular disease stages, to death, in people with known cardiovascular disease. Contrary to the observations for primary prevention, we found associations that could suggest beneficial effects between regular use of fish oil supplements and most cardiovascular disease transitions. No associations were found between regular use of fish oil supplements and transitions from atrial fibrillation to death, or from major adverse cardiovascular events to death.

Consistent with our hypothesis, the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI) Prevenzione study reported an association between administration of low dose prescriptions of n-3 polyunsaturated fatty acids and reduced cardiovascular events in patients with recent myocardial infarction. 27 A meta-analysis of 16 randomised controlled trials also reported a tendency towards a greater beneficial effect for secondary prevention in patients with cardiovascular disease. 28 Why patients with previous atrial fibrillation benefit is unclear. These findings indicate that triglyceride independent effects of omega 3 fatty acids might in part be responsible for the benefits in cardiovascular disease seen in previous trials. 29–31 No proven biological mechanism for this explanation exists, however, and the dose and formulation of omega 3 fatty acids used in clinical practice are not known.

For the disease process, from cardiovascular disease to death, our findings are consistent with the results of secondary prevention trials of omega 3 fatty acids, which have mostly shown a weak or neutral preventive effect in all cause mortality with oil fish supplements. The GISSI heart failure trial (GISSI-HF), conducted in 6975 patients with chronic heart failure, reported that supplemental omega 3 fatty acids reduced the risk of all cause mortality by 9% (hazard ratio 0.91, 95% CI 0.833 to 0.998, P=0.041). 32 Zelniker et al showed that omega 3 fatty acids were inversely associated with a lower incidence of sudden cardiac death in patients with non-ST segment elevation acute coronary syndrome. 33 A meta-analysis found that use of omega 3 supplements of ≤1 capsule/day was not associated with all cause mortality, but among participants with a risk of cardiovascular disease, taking a higher dose was associated with a reduction in cardiac death and sudden death. 28 Individuals who might benefit the most from fish oil or omega 3 fatty acid supplements are possibly more vulnerable individuals, such as those with previous cardiovascular diseases and those who can no longer live in the community. How fish oil supplements stop further deterioration of cardiovascular disease is unclear, but the theory that supplemental omega 3 fatty acids might protect the coronary artery is biologically plausible, suggesting that omega 3 fatty acids have anti-inflammatory and anti-hypertriglyceridaemia effects, contributing to a reduction in thrombosis and improvement in endothelial function. 34–41 Nevertheless, the effects of omega 3 fatty acids vary according to an individual's previous use of statins, which might partly explain the different effects of fish oil supplements in people with and without cardiovascular disease.

Many studies of omega 3 fatty acids, including large scale clinical trials and meta-analyses, have not produced entirely consistent results. 21 25 42 Our study mainly explored the varied potential effects of regular use of fish oil supplements on progression of cardiovascular disease, offering an initial overview of this ongoing discussion. Our findings suggest caution in the use of fish oil supplements for primary prevention because of the uncertain cardiovascular benefits and adverse effects. Further studies are needed to determine whether potential confounders modify the effects of oil fish supplements and the precise mechanisms related to the development and prognosis of cardiovascular disease events.

Strengths and limitations of this study

The strengths of our study were the large sample size, long follow-up period, which allowed us to analyse clinically diagnosed incident diseases, and complete data on health outcomes. Another strength was our analytical strategy. The multi-state model gives less biased estimates than the conventional Cox model, and distinguished the effect of regular use of fish oil supplements on each transition in the course of cardiovascular disease.

Our study had some limitations. Firstly, as an observational study, no causal relations can be drawn from our findings. Secondly, although we adjusted for multiple covariates, residual confounding could still exist. Thirdly, information on dose and formulation of the fish oil supplements was not available in this study, so we could not evaluate potential dose dependent effects or differentiate between the effects of different fish oil formulations. Fourthly, the use of hospital inpatient data for determining atrial fibrillation events could have excluded some events triggered by acute episodes, such as surgery, trauma, and similar conditions, resulting in underestimation of the true risk because undiagnosed atrial fibrillation is a common occurrence. 43 Fifthly, most of the participants in this study were from the white ethnic group and whether the findings can be generalised to other ethnic groups is not known. Finally, our study did not consider behavioural changes in populations with different cardiovascular profiles because of limited information, and variations in outcomes for different cardiovascular states merits further exploration.

Conclusions

This large scale prospective study of a UK cohort suggested that regular use of fish oil supplements might have differential roles in the course of cardiovascular diseases. Regular use of fish oil supplements might be a risk factor for atrial fibrillation and stroke among the general population but could be beneficial for disease progression, from atrial fibrillation to major adverse cardiovascular events, and from atrial fibrillation to death. Further studies are needed to determine whether potential confounders modify the effects of oil fish supplements and the precise mechanisms for the development and prognosis of cardiovascular disease events.

Ethics statements

Patient consent for publication.

Consent obtained directly from patients.

Ethics approval

The UK Biobank study obtained ethical approval from the North West Multicentre Research ethics committee, Information Advisory Group, and the Community Health Index Advisory Group (REC reference for UK Biobank 11/NW/0382). Participants gave informed consent to participate in the study before taking part.

Acknowledgments

This study was conducted with UK Biobank Resource (application No: 69550). We appreciate all participants and professionals contributing to UK Biobank.

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GYL and HL are joint senior authors.

Contributors HL supervised the whole project and designed the work. GC and HL directly accessed and verified the underlying data reported in the manuscript. GC contributed to data interpretation and writing of the report. ZQ, SZ, JZ, ZZ, MGV, HEA, CW, and GYHL contributed to the discussion and data interpretation, and revised the manuscript. All authors had full access to all of the data in the study and had final responsibility for the decision to submit for publication. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. HL is the guarantor. Transparency: The lead author (guarantor) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

Funding This work was supported by the Bill and Melinda Gates Foundation (grant No INV-016826). Under the grant conditions of the foundation, a creative commons attribution 4.0 generic license has already been assigned to the author accepted manuscript version that might arise from this submission. The funder had no role in considering the study design or in the collection, analysis, interpretation of data, writing of the report, or decision to submit the article for publication.

Competing interests All authors have completed the ICMJE uniform disclosure form at www.icmje.org/disclosure-of-interest/ and declare: support from Bill and Melinda Gates Foundation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

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Why New Dietary Guidelines In India Have Advised Avoiding Protein Supplements

The new guidelines, which include evidence-based food and lifestyle-related recommendations, called out against the need for protein supplements.

ICMR has pressed for avoiding protein supplements for building body mass. (Representational)

Protein supplements, which come with added sugars and additives, may harm the kidneys and bones and are not required for healthy people, said experts on Tuesday, even as the ICMR-NIN's new dietary guidelines also advise against them.

The Indian Council of Medical Research and National Institute of Nutrition (ICMR-NIN), last week, released 17 dietary guidelines to prevent nutrient deficiencies, as well as address the rising risk of obesity, diabetes, and cardiovascular diseases in India.

It noted that a healthy and proper diet is enough to fulfil the protein requirements of all individuals.

As per the new guidelines, the recommendation for protein is 0.83g/kg/day, and the estimated average intake is 0.66 g/kg/day.

"With increased knowledge and information about micronutrients and their importance in a balanced diet, people have resorted to protein powder, protein supplements, among other artificial nutritional supplements," Dr. N Vijayshree, Head and Chief Dietician of MGM Healthcare told IANS.

"These protein powders are usually made with eggs, milk, whey, or plant sources such as soy, peas, or rice, sometimes with a mix of these sources.

"These supplements, with added sugars and additives, defeat the purpose of having a balanced diet, causing severe or more damage to our kidneys and bone health," the doctor added.

Vani Krishna, Chief Nutritionist, at Manipal Hospital Varthur, told IANS that protein intake can be achieved by adding legumes, pulses, nuts, seeds, eggs, poultry, fish, etc with a balanced diet for all age groups.

"An individual's protein intake has to be assessed and checked by a qualified clinical nutritionist before administering any kind of protein powders/supplements. For obtaining good quality protein, a combination of cereals with pulses in the ratio of 3:1 will help to meet the amino acids needed in the body," Vani said.

Dr. Vijayshree also advised physical activity to use the protein consumed and avoid muscle loss, as well as an adequate amount of carbs and fats for the effective utilisation of the consumed protein.

"A balanced diet must meet the need for 20 essential amino acids required for bodily functions. To obtain some of these amino acids, which cannot be synthesised in our body, it is important to consume diverse food groups like carbohydrates, fats, and protein.

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"Protein supplements are not recommended for normal, healthy people. Critically ill, hospitalised patients may require protein supplements, which should be recommended and monitored by clinical professionals," Dr. Vijayshree said.  

(Except for the headline, this story has not been edited by NDTV staff and is published from a syndicated feed.)

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Collagen is the most abundant protein in the body. Its fiber-like structure is used to make connective tissue. Like the name implies, this type of tissue connects other tissues and is a major component of bone, skin, muscles, tendons, and cartilage. It helps to make tissues strong and resilient, able to withstand stretching.

In food, collagen is naturally found only in animal flesh like meat and fish that contain connective tissue. However, a variety of both animal and plant foods contain materials for collagen production in our own bodies.

Our bodies gradually make less collagen as we age, but collagen production drops most quickly due to excess sun exposure, smoking, excess alcohol, and lack of sleep and exercise . With aging, collagen in the deep skin layers changes from a tightly organized network of fibers to an unorganized maze. [1] Environmental exposures can damage collagen fibers reducing their thickness and strength, leading to wrinkles on the skin’s surface.

Collagen Supplementation

Despite its abundance in our bodies, collagen has become a top-selling supplement purported to improve hair, skin, and nails—key components of the fountain of youth. The idea of popping a pill that doesn’t have side effects and may reverse the signs of aging is attractive to many. According to Google Trends, online searches for collagen have steadily increased since 2014.

Collagen first appeared as an ingredient in skin creams and serums. However, its effectiveness as a topical application was doubted even by dermatologists, as collagen is not naturally found on the skin’s surface but in the deeper layers. Collagen fibers are too large to permeate the skin’s outer layers, and research has not supported that shorter chains of collagen, called peptides, are more successful at this feat.

Oral collagen supplements in the form of pills, powders, and certain foods are believed to be more effectively absorbed by the body and have skyrocketed in popularity among consumers. They may be sold as collagen peptides or hydrolyzed collagen, which are broken down forms of collagen that are more easily absorbed. Collagen supplements contain amino acids, the building blocks of protein , and some may also contain additional nutrients related to healthy skin and hair like vitamin C , biotin , or zinc .

What does the research say on collagen supplements?

Most research on collagen supplements is related to joint and skin health. Human studies are lacking but some randomized controlled trials have found that collagen supplements improve skin elasticity. [3,4] Other trials have found that the supplements can improve joint mobility and decrease joint pain such as with osteoarthritis or in athletes. [5] Collagen comprises about 60% of cartilage, a very firm tissue that surrounds bones and cushions them from the shock of high-impact movements; so a breakdown in collagen could lead to a loss of cartilage and joint problems.

However, potential conflicts of interest exist in this area because most if not all of the research on collagen supplements are funded or partially funded by related industries that could benefit from a positive study result, or one or more of the study authors have ties to those industries. This makes it difficult to determine how effective collagen supplements truly are and if they are worth their often hefty price.

A downside of collagen supplements is the unknown of what exactly it contains or if the supplement will do what the label promotes. There are also concerns of collagen supplements containing heavy metals. In the U.S., the Food and Drug Administration does not review supplements for safety or effectiveness before they are sold to consumers.

Another potential downside is that taking a collagen supplement can become an excuse to not practice healthy behaviors that can protect against collagen decline, such as getting enough sleep and stopping smoking.

That said, the available research has not shown negative side effects in people given collagen supplements. [3,4]

Can You Eat Collagen?

Food containing collagen

• There are foods rich in collagen, specifically tough cuts of meat full of connective tissue like pot roast, brisket, and chuck steak. However, a high intake of red meat is not recommended as part of a long-term healthy and environmentally sustainable diet . Collagen is also found in the bones and skin of fresh and saltwater fish. [2]
• Bone broth, a trending food featured prominently in soup aisles, is promoted as a health food rich in collagen. The process involves simmering animal bones in water and a small amount of vinegar (to help dissolve the bone and release collagen and minerals) anywhere from 4 to 24 hours. However, the amount of amino acids will vary among batches depending on the types of bones used, how long they are cooked, and the amount of processing (e.g., if it is a packaged/canned version).
• Gelatin is a form of collagen made by boiling animal bones, cartilage, and skin for several hours and then allowing the liquid to cool and set. The breakdown of these connective tissues produces gelatin. Collagen and its derivative, gelatin, are promoted on certain eating plans such as the paleo diet .

Foods to boost collagen production

• Several high-protein foods are believed to nurture collagen production because they contain the amino acids that make collagen—glycine, proline, and hydroxyproline. [6] These include fish, poultry, meat, eggs , dairy , legumes , and soy .
• Collagen production also requires nutrients like zinc that is found in shellfish, legumes, meats, nuts , seeds, and whole grains ; and vitamin C from citrus fruits, berries, leafy greens, bell peppers, and tomatoes.

Is bone broth healthy?

In reality, bone broth contains only small amounts of minerals naturally found in bone including calcium , magnesium , potassium , iron , phosphorus , sodium , and copper. The amount of protein , obtained from the gelatin, varies from 5-10 grams per cup.

There is some concern that bone broth contains toxic metals like lead. One small study found that bone broth made from chicken bones contained three times the lead as chicken broth made with the meat only. [7] However the amount of lead in the bone broth per serving was still less than half the amount permitted by the Environmental Protection Agency in drinking water. A different study found that bone broth, both homemade and commercially produced, contained low levels (<5% RDA) of calcium and magnesium as well as heavy metals like lead and cadmium. [9] The study noted that various factors can affect the amount of protein and minerals extracted in bone broth: the amount of acidity, cooking time, cooking temperature, and type of animal bone used. Therefore it is likely that the nutritional value of bone broths will vary widely.

Healthy Lifestyle Habits That May Help  

Along with a healthy and balanced diet , here are some habits that may help protect your body’s natural collagen:

• Wear sunscreen or limit the amount of time spent in direct sunlight (10-20 minutes in direct midday sunlight 3-4 times a week provides adequate vitamin D for most people).
• Get adequate sleep . For the average person, this means 7-9 hours a night.
• Avoid smoking or secondhand smoke.
• Control stress . Chronically high cortisol levels can decrease collagen production.
• Although the exact connection between exercise and skin quality is unclear, some studies have found that exercise slows down cell activity involved with aging skin. [10]  

Bottom Line

At this time, non-industry funded research on collagen supplements is lacking. Natural collagen production is supported through a healthy and balanced diet by eating enough protein foods , whole grains , fruits, and vegetables and reducing lifestyle risk factors.

• Rinnerhaler M, Bischof J, Streubel MK, Trost A, Richter K. Oxidative Stress in Aging Human Skin. Biomolecules . 2015 Apr 21;5(2):545-89.
• Avila Rodríguez MI, Rodriguez Barroso LG, Sánchez ML. Collagen: A review on its sources and potential cosmetic applications. Journal of Cosmetic Dermatology . 2018 Feb;17(1):20-6.
• Proksch E, Segger D, Degwert J, Schunck M, Zague V, Oesser S. Oral supplementation of specific collagen peptides has beneficial effects on human skin physiology: a double-blind, placebo-controlled study. Skin pharmacology and physiology . 2014;27(1):47-55.
• Kim DU, Chung HC, Choi J, Sakai Y, Lee BY. Oral intake of low-molecular-weight collagen peptide improves hydration, elasticity, and wrinkling in human skin: a randomized, double-blind, placebo-controlled study. Nutrients . 2018 Jul;10(7):826.
• Bello AE, Oesser S. Collagen hydrolysate for the treatment of osteoarthritis and other joint disorders: a review of the literature. Current medical research and opinion . 2006 Nov 1;22(11):2221-32.
• Lodish H, Berk A, Zipursky SL, et al. Molecular Cell Biology . New York: W. H. Freeman; 2000.
• Monro JA, Leon R, Puri BK. The risk of lead contamination in bone broth diets. Medical hypotheses . 2013 Apr 1;80(4):389-90.
• Global Market Insights. Worldwide Broth Market . Feb 26, 2018.
• Hsu DJ, Lee CW, Tsai WC, Chien YC. Essential and toxic metals in animal bone broths. Food & nutrition research . 2017 Jan 1;61(1):1347478.
• Crane JD, MacNeil LG, Lally JS, Ford RJ, Bujak AL, Brar IK, Kemp BE, Raha S, Steinberg GR, Tarnopolsky MA. Exercise‐stimulated interleukin‐15 is controlled by AMPK and regulates skin metabolism and aging. Aging cell . 2015 Aug;14(4):625-34.

Last reviewed May 2021

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• About Adverse Childhood Experiences
• Risk and Protective Factors
• Program: Essentials for Childhood: Preventing Adverse Childhood Experiences through Data to Action
• Adverse childhood experiences can have long-term impacts on health, opportunity and well-being.
• Adverse childhood experiences are common and some groups experience them more than others.

What are adverse childhood experiences?

Adverse childhood experiences, or ACEs, are potentially traumatic events that occur in childhood (0-17 years). Examples include: 1

• Experiencing violence, abuse, or neglect.
• Witnessing violence in the home or community.
• Having a family member attempt or die by suicide.

Also included are aspects of the child’s environment that can undermine their sense of safety, stability, and bonding. Examples can include growing up in a household with: 1

• Substance use problems.
• Mental health problems.
• Instability due to parental separation.
• Instability due to household members being in jail or prison.

The examples above are not a complete list of adverse experiences. Many other traumatic experiences could impact health and well-being. This can include not having enough food to eat, experiencing homelessness or unstable housing, or experiencing discrimination. 2 3 4 5 6

Quick facts and stats

ACEs are common. About 64% of adults in the United States reported they had experienced at least one type of ACE before age 18. Nearly one in six (17.3%) adults reported they had experienced four or more types of ACEs. 7

Preventing ACEs could potentially reduce many health conditions. Estimates show up to 1.9 million heart disease cases and 21 million depression cases potentially could have been avoided by preventing ACEs. 1

Some people are at greater risk of experiencing one or more ACEs than others. While all children are at risk of ACEs, numerous studies show inequities in such experiences. These inequalities are linked to the historical, social, and economic environments in which some families live. 5 6 ACEs were highest among females, non-Hispanic American Indian or Alaska Native adults, and adults who are unemployed or unable to work. 7

ACEs are costly. ACEs-related health consequences cost an estimated economic burden of $748 billion annually in Bermuda, Canada, and the United States. 8

ACEs can have lasting effects on health and well-being in childhood and life opportunities well into adulthood. 9 Life opportunities include things like education and job potential. These experiences can increase the risks of injury, sexually transmitted infections, and involvement in sex trafficking. They can also increase risks for maternal and child health problems including teen pregnancy, pregnancy complications, and fetal death. Also included are a range of chronic diseases and leading causes of death, such as cancer, diabetes, heart disease, and suicide. 1 10 11 12 13 14 15 16 17

ACEs and associated social determinants of health, such as living in under-resourced or racially segregated neighborhoods, can cause toxic stress. Toxic stress, or extended or prolonged stress, from ACEs can negatively affect children’s brain development, immune systems, and stress-response systems. These changes can affect children’s attention, decision-making, and learning. 18

Children growing up with toxic stress may have difficulty forming healthy and stable relationships. They may also have unstable work histories as adults and struggle with finances, jobs, and depression throughout life. 18 These effects can also be passed on to their own children. 19 20 21 Some children may face further exposure to toxic stress from historical and ongoing traumas. These historical and ongoing traumas refer to experiences of racial discrimination or the impacts of poverty resulting from limited educational and economic opportunities. 1 6

Adverse childhood experiences can be prevented. Certain factors may increase or decrease the risk of experiencing adverse childhood experiences.

Preventing adverse childhood experiences requires understanding and addressing the factors that put people at risk for or protect them from violence.

Creating safe, stable, nurturing relationships and environments for all children can prevent ACEs and help all children reach their full potential. We all have a role to play.

• Merrick MT, Ford DC, Ports KA, et al. Vital Signs: Estimated Proportion of Adult Health Problems Attributable to Adverse Childhood Experiences and Implications for Prevention — 25 States, 2015–2017. MMWR Morb Mortal Wkly Rep 2019;68:999-1005. DOI: http://dx.doi.org/10.15585/mmwr.mm6844e1 .
• Cain KS, Meyer SC, Cummer E, Patel KK, Casacchia NJ, Montez K, Palakshappa D, Brown CL. Association of Food Insecurity with Mental Health Outcomes in Parents and Children. Science Direct. 2022; 22:7; 1105-1114. DOI: https://doi.org/10.1016/j.acap.2022.04.010 .
• Smith-Grant J, Kilmer G, Brener N, Robin L, Underwood M. Risk Behaviors and Experiences Among Youth Experiencing Homelessness—Youth Risk Behavior Survey, 23 U.S. States and 11 Local School Districts. Journal of Community Health. 2022; 47: 324-333.
• Experiencing discrimination: Early Childhood Adversity, Toxic Stress, and the Impacts of Racism on the Foundations of Health | Annual Review of Public Health https://doi.org/10.1146/annurev-publhealth-090419-101940 .
• Sedlak A, Mettenburg J, Basena M, et al. Fourth national incidence study of child abuse and neglect (NIS-4): Report to Congress. Executive Summary. Washington, DC: U.S. Department of Health an Human Services, Administration for Children and Families.; 2010.
• Font S, Maguire-Jack K. Pathways from childhood abuse and other adversities to adult health risks: The role of adult socioeconomic conditions. Child Abuse Negl. 2016;51:390-399.
• Swedo EA, Aslam MV, Dahlberg LL, et al. Prevalence of Adverse Childhood Experiences Among U.S. Adults — Behavioral Risk Factor Surveillance System, 2011–2020. MMWR Morb Mortal Wkly Rep 2023;72:707–715. DOI: http://dx.doi.org/10.15585/mmwr.mm7226a2 .
• Bellis, MA, et al. Life Course Health Consequences and Associated Annual Costs of Adverse Childhood Experiences Across Europe and North America: A Systematic Review and Meta-Analysis. Lancet Public Health 2019.
• Adverse Childhood Experiences During the COVID-19 Pandemic and Associations with Poor Mental Health and Suicidal Behaviors Among High School Students — Adolescent Behaviors and Experiences Survey, United States, January–June 2021 | MMWR
• Hillis SD, Anda RF, Dube SR, Felitti VJ, Marchbanks PA, Marks JS. The association between adverse childhood experiences and adolescent pregnancy, long-term psychosocial consequences, and fetal death. Pediatrics. 2004 Feb;113(2):320-7.
• Miller ES, Fleming O, Ekpe EE, Grobman WA, Heard-Garris N. Association Between Adverse Childhood Experiences and Adverse Pregnancy Outcomes. Obstetrics & Gynecology . 2021;138(5):770-776. https://doi.org/10.1097/AOG.0000000000004570 .
• Sulaiman S, Premji SS, Tavangar F, et al. Total Adverse Childhood Experiences and Preterm Birth: A Systematic Review. Matern Child Health J . 2021;25(10):1581-1594. https://doi.org/10.1007/s10995-021-03176-6 .
• Ciciolla L, Shreffler KM, Tiemeyer S. Maternal Childhood Adversity as a Risk for Perinatal Complications and NICU Hospitalization. Journal of Pediatric Psychology . 2021;46(7):801-813. https://doi.org/10.1093/jpepsy/jsab027 .
• Mersky JP, Lee CP. Adverse childhood experiences and poor birth outcomes in a diverse, low-income sample. BMC pregnancy and childbirth. 2019;19(1). https://doi.org/10.1186/s12884-019-2560-8 .
• Reid JA, Baglivio MT, Piquero AR, Greenwald MA, Epps N. No youth left behind to human trafficking: Exploring profiles of risk. American journal of orthopsychiatry. 2019;89(6):704.
• Diamond-Welch B, Kosloski AE. Adverse childhood experiences and propensity to participate in the commercialized sex market. Child Abuse & Neglect. 2020 Jun 1;104:104468.
• Shonkoff, J. P., Garner, A. S., Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption, and Dependent Care, & Section on Developmental and Behavioral Pediatrics (2012). The lifelong effects of early childhood adversity and toxic stress. Pediatrics, 129(1), e232–e246. https://doi.org/10.1542/peds.2011-2663
• Narayan AJ, Kalstabakken AW, Labella MH, Nerenberg LS, Monn AR, Masten AS. Intergenerational continuity of adverse childhood experiences in homeless families: unpacking exposure to maltreatment versus family dysfunction. Am J Orthopsych. 2017;87(1):3. https://doi.org/10.1037/ort0000133 .
• Schofield TJ, Donnellan MB, Merrick MT, Ports KA, Klevens J, Leeb R. Intergenerational continuity in adverse childhood experiences and rural community environments. Am J Public Health. 2018;108(9):1148-1152. https://doi.org/10.2105/AJPH.2018.304598 .
• Schofield TJ, Lee RD, Merrick MT. Safe, stable, nurturing relationships as a moderator of intergenerational continuity of child maltreatment: a meta-analysis. J Adolesc Health. 2013;53(4 Suppl):S32-38. https://doi.org/10.1016/j.jadohealth.2013.05.004 .

Adverse Childhood Experiences (ACEs)

ACEs can have a tremendous impact on lifelong health and opportunity. CDC works to understand ACEs and prevent them.

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