Resistance Women PDF Free Download

admin 10/13/2021
MovieDownload
Accepted Manuscript Title: Effect of omega-3 fatty acids supplementation on Insulin resistance in women with polycystic ovary syndrome: Meta-analysis of randomized controlled trials Author: Alirez Sadeghi Kurosh Djafarian Hamed Mohammadi Sakineh Shab-Bidar PII: DOI: Reference:
S1871-4021(16)30093-5 http://dx.doi.org/doi:10.1016/j.dsx.2016.06.025 DSX 615
To appear in:
Diabetes & Metabolic Syndrome: Clinical Research & Reviews
Please cite this article as: Sadeghi Alirez, Djafarian Kurosh, Mohammadi Hamed, Shab-Bidar Sakineh.Effect of omega-3 fatty acids supplementation on Insulin resistance in women with polycystic ovary syndrome: Meta-analysis of randomized controlled trials.Diabetes and Metabolic Syndrome: Clinical Research and Reviews http://dx.doi.org/10.1016/j.dsx.2016.06.025 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Effect of omega-3 fatty acids supplementation on Insulin resistance in women with
1
polycystic ovary syndrome: Meta-analysis of randomized controlled trials
2
Effect of omega-3 fatty acids supplementation on Insulin resistance in women with
3
polycystic ovary syndrome: Meta-analysis of randomized controlled trials
4
Alirez Sadeghi1, Kurosh Djafarian2, Hamed Mohammadi1, Sakineh Shab-Bidar3
5
1 Department of Cellular and Molecular Nutrition, School of Nutritional Sciences and Dietetics,
6
Tehran University of Medical Sciences (TUMS), Tehran, Iran
7
2 Department of Clinical Nutrition, School of Nutritional Sciences and Dietetics, Tehran
8
University of Medical Sciences (TUMS), Tehran, Iran
9
3 Department of community Nutrition, School of Nutritional Sciences and Dietetics, Tehran
10
University of Medical Sciences (TUMS), Tehran, Iran
11
*Corresponding Author:
12
* Address for correspondence:
13
Sakineh Shab-Bidar, Ph.D. Assistant Professor
14
Address: Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran
15
University of Medical Sciences, Tehran, Iran
16
Email: [email protected]
17
Tel: 982188955979
18 19 20 21
Abstract
22
Background: Several studies have shown that omega-3 polyunsaturated fatty acids (PUFA)
23
may improve insulin resistance in various diseases. However, the possible effect of
24
1
eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) supplementation on
25
insulin resistance in PCOS still remains unclear. We evaluated the effect of omega-3 PUFA
26
supplementation on insulin resistance in women with PCOS in a meta-analysis.
27
Methods: Literature searches of MEDLINE, PubMed Central and EMBASE for publications
28
in English were conducted up to December 2015. We included all randomized controlled
29
trials (RCTs) that investigated effects of omega-3 fatty acids supplements on insulin
30
resistance in women with PCOS. Results are summarized as mean differences (MD) with
31
95% confidence intervals (CI). Effect sizes of eligible studies were pooled using random-
32
effects models (the DerSimonian-Laird estimator). We assessed the potential sources of
33
heterogeneity using the standard χ2 test.
34
Results: Of 1202 papers, three RCTs were eligible for inclusion which involved 72 cases and
35
73 controls. The dose range for omega3 supplement was 1.2 g to 3.6 g and the duration of
36
follow-up was from 6 to 8 weeks. There was no significant effect of omega-3 fatty acids
37
supplements compared to placebo on insulin resistance (MD: 6.18 ; CI; -3.347 , 15.382 ; p
38
=0.208 ) and HOMA –IR (MD: 0.276
39
; 95% CI = -1.428 , 1.981; p =0.751 ) in women with
PCOS .
40
Conclusion: The results provide an evidence that supplementation with omega-3 fatty acids
41
may not have a beneficial effect on improving insulin resistance in women with PCOS.
42
Key words: Polycystic ovary syndrome; polyunsaturated fatty acids; randomized controlled
43
trials
44 45
2
Introduction
46
Polycystic ovary syndrome (PCOS) is the most common and complex endocrine disorder that
47
affect fertility of women in their reproductive age
(1; 2)
. Prevalence of PCOS in the general (3; 4)
48
. PCOS is
49
. This syndrome is also
50
related to dyslipidemia, insulin resistance, type 2 diabetes and risk factors of cardiovascular
51
disease such as elevated levels of high-sensitivity C-reactive protein(hs-CRP) and acute
52
population is 5%-18% that varies according to the diagnostic criteria characterized by hyperandrogenism and ovulatory dysfunction
(5; 6)
(7; 8)
. Insulin resistance with hyperinsulinaemia is common in PCOS which is
53
also seen in 50-70 % of lean and obese women with this syndrome (9; 10). Moreover, PCOS is
54
a proinflammatory disease with increased level of tumor necrosis factor alpha (TNF-α) and
55
phase proteins
(4; 11)
.
56
Insulin resistance may play a key role in the pathogenesis of PCOS, and hyperinsulinemia
57
may lead to hyperandrogenaemia by stimulation of androgen synthesis through Theca cells
58
and reducing hepatic production of sex hormone-binding globulin (SHBG) (10; 12).
59
Lifestyle and nutritional interventions along with weight loss are successful treatment for
60
Interleukin-6 (IL-6) in obese and lean women which may lead to insulin resistance
women with PCOS
(6; 13)
. Dietary factors such as anti-inflammatory foods may have (6; 14)
61
. Among dietary
62
factors, omega-3 fatty acids especially marine n-3 PUFA (eicosapentaenoic acid (C20∶5n-3,
63
EPA) and docosahexaenoic acid (C22∶6n-3, DHA)) have anti-inflammatory, anti-obesity and
64
anti-insulin resistance functions (14; 15; 16). Omega 3 fatty acids can improve insulin sensitivity
65
by decreasing production of inflammatory cytokines including TNFα, IL-6 and increasing
66
secretion of anti-inflammatory adiponectin (17). Although several studies have shown effect of
67
omega-3 fatty acids on insulin resistance in different conditions, but there are controversial
68
results in studies on PCOS patients (6). Thus, in current meta-analysis we intend to investigate
69
the effect of omega-3 supplementation on insulin resistance in women with PCOS.
70
important role in improving metabolic disorders of this syndrome
3
Methods
71
Search strategy and selection criteria
72
The Preferred Reporting Items for Systematic Reviews and Meta-Analyses was used for
73
writing this systematic review and meta-analysis (18).
74
We searched databases including MEDLINE, EMBASE and PubMed Central for all relevant
75
published studies up to December 2015 with no language restriction. We used medical
76
subject headings (MeSH) and text words to identify potential interest articles. Search terms
77
included: ('Fatty Acids, Omega-3' OR 'n-3 polyunsaturated fatty acid ' OR 'omega-3
78
polyunsaturated fatty acid' OR 'ω-3fatty acid' OR 'polyunsaturated fatty acid' OR
79
'eicosapentaenoic acid' OR 'docosahexaenoic acid' OR 'fish oil' OR EPA OR DHA OR
80
ALA OR PUFA OR 'alpha-linolenic acid' OR fat OR 'fatty acid' OR 'docosapentaenoic
81
acid' OR n-3 OR omega-3 OR 'n-3 fatty acid') AND ('polycystic ovarian syndrome' OR
82
PCO OR PCOS OR 'polycystic ovary' OR 'Polycystic Ovary Syndrome'). First, there was
83
no limitation on RCT, animals or human studies. Then, among the all received articles, RCTs
84
were identified by reading titles, abstracts, population and study design in order to select
85
relevant articles for inclusion/exclusion criteria.
86
Eligibility criteria
87
Studies were eligible for inclusion if they fulfilled the following criteria: a) the study design
88
was a RCT, b) the intervention was oral omega-3 supplementation, c) the outcomes of
89
interest were insulin resistance, d) the population of interest was adults (aged > 18 years).
90
Studies were excluded if those were cross-sectional, review articles, duplicated publications
91
and animal or cell culture studies.
92
Quality assessment
93 (19)
. The Jadad
94
scale contains questions which describe randomization, randomization scheme and
95
We used Jadad scoring system to assess the quality of the included studies
4
withdrawal in intervention and placebo group (20) . In this scoring system each study get from
96
zero to five points. Low quality studies received score of ≤ 2 and high quality studies a score
97
of ≥ 3 (20).
98
Data extraction and Statistical Analysis
99
The following data were extracted from full text of selected studies: general characteristics of
100
the study (first author’s name, year of publication, the study design, the country where the
101
study was conducted, number of cases and controls, total supplement dose and duration of
102
follow-up), characteristics of the participants (study population, age, BMI) and result (means
103
and standard deviations for insulin and HOMA-IR in baseline and After intervention).
104
Heterogeneity of studies was assessed using the I2 statistics. A random-effects model (the
105
DerSimonian-Laird estimator) was used if heterogeneity was more than 50%, to calculate the
106
pooled mean difference (MD).
107
All statistical analysis was performed using STATA software version 12 (STATA Corp,
108
College station, Texas).
109
Results
110
Study selection
111
The flow chart of the study is presented in Figure 1. The initial search identified 1202 studies
112
through PubMed and Scopus; 808 studies remained after removing duplicates. The title and
113
abstract of remaining studies were reviewed and irrelevant studies were excluded. A total 6
114
studies were eligible for inclusion in the meta-analysis. One study had no control group, one
115
study was overlapped and in another study there was limited data
(10; 21; 22)
. Finally, 3
116
randomized controlled trials were included in this meta-analysis.
117
Characteristics of included studies
118
5
Characteristics of the included studies were summarized in Table 1. The Rotterdam
119
diagnostic criteria and the NIH criteria were used in all studies whereas one study
120
(23; 24)
. These studies were published in
121
which included 72 cases and 73 controls. All were
122
published between 2009 and 2012. The duration of follow-up was from 6 to 8 weeks. All
123
studies had parallel design nevertheless one study was crossover with 6 and 8 weeks washout
124
period (24). The cases received daily omega3 supplement which contain EPA and DHA in the
125
range of 1.2 g to 3.6 g (median: 2.7) and control group received the placebo in the form of
126
investigated only overweight/obese PCOS women Iran
(25)
, Australia
(24)
(26)
and USA
(24; 25; 26)
. Plasma fatty acid composition
127
. Two studies asked participants to maintain usual dietary
128
intake during intervention (24) and two studies obtained information about daily energy intake
129
olive oil , soybean oil or other placebo oral agents was assessed only in one study
(25)
at the beginning and the end of the intervention
(25; 26)
. The quality of our study was assessed
using Jadad Scale, and only one study scored < 3 on the Jadad scale
(24)
. All three included
130 131
studies were double-blinded and randomization was described in all these studies.
132
Meta-analysis
133
The effects of omega-3 fatty acids supplementation on insulin resistance were shown in
134
Figures 2-3. Intake of omega-3 fatty acids had no significant effects on insulin plasma level
135
(MD: 6.018; 95% CI = -3.347, 15.382; p = 0.208) and HOMA –IR (MD: 0.276; 95% CI = -
136
1.428, 1.981; p = 0.751) in PCOS subjects with high heterogeneity for both insulin (p =
137
0.000, and I2 =92.7% ) and HOMA (p = 0.000, and I2 =96.3%).
138
Discussion
139
The results obtained in the current meta-analysis study revealed no beneficial effect of taking
140
omega-3 fatty acid supplements on insulin resistant in women with PCOS. To the best of the
141
researchers' knowledge, this is the first study that investigated the influence of omega-3 fatty
142
acid supplements on insulin resistance in patients with PCOS.
143 6
Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorders that women suffer from
(27)
. In addition to high levels of androgens and anovulation, PCOS is (8; 10)
144 145
. Insulin
146
(10; 12;
147
. Accordingly, reducing the levels of serum insulin and increasing insulin sensitivity are
148
usually accompanied with some other disorders including insulin resistance
resistance can stimulate the production and secretion of androgens and ovarian failure 28)
(15)
. Omega-3fatty
149
acids may lead to insulin sensitivity by producing and secreting anti-inflammatory adipokine
150
such as adiponectin and also through reducing inflammation and proinflammatory cytokines
151
(11; 15; 25; 29)
152
resistance, various studies have indicated contradictory results.
153
Studies conducted on mice have shown that omega-3 fatty acids can prevent insulin
154
resistance by activating PPARα, reducing inflammation and accumulating fat in tissues
155
considered to be of paramount importance for therapeutic targets in PCOS
. Although it is said that omega-3 fatty acids have positive effects on insulin
(30; 31)
. Goner et al. found that omega-3 fatty acids may play a role in the
156
reduction of insulin resistance in patients with PCOS. This can be done without influencing
157
sensitive to insulin
(15)
. Besides, Mohammadi et al. stated that supplementation with omega-3
158
fatty acids increases the levels of adiponectin and reduces insulin resistance in women with
159
PCOS. This results were similar to the results of other studies that reported reduced fasting
160
hormone profiles
(25; 32; 33)
.
161
Moreover, another study which was conducted on hyperlipidemic patients, revealed that
162
receiving EPA has a meaningful effect with the reduction of levels of serum insulin and
163
HOMA-IR (34).
164
In contrast, some studies indicated that the supplementation with omega-3 fatty acids does
165
not influence insulin resistance. In a clinical and experimental study, which was carried out
166
by M. Luisa Varges et al, the researchers reported that omega-3 fatty acids can reduce the
167
serum glucose in healthy women and reduction in HOMA-IR in young female
initial release of insulin, decrease glucose tolerance, and increase insulin levels
(26)
. To test
7
168
this finding, effects of n-3 PUFA in diabetes should be compared with the control group. In
169
addition, in this study there was no significant increase in adiponectin during fish oil
170
intervention, while studies in animal models and humans have reported such significant
171
increase.
172
According to a meta-analysis conducted by Akinkuolie et al. no relationship was observed
173
between omega-3 fatty acids and insulin resistance (35). This is in line with what the previous
174
meta-analysis studies have found in this respect.
175
It seems that differences related to the supplementation with omega-3 fatty acids stem from
176
the dosage, trial duration, lack of control group, obesity and severity of insulin resistance and
177
the presence of other conditions that influence the insulin resistance. In the current meta-
178
analysis study, the researchers attempted to investigate the influence of omega-3
179
supplementation on insulin resistance by employing the clinical evidence available. However,
180
no beneficial effects on insulin resistance were observed by taking omega-3 fatty acids.
181
Limitations
182
The current study has certain limitations. First, the number of included trials as well as the
183
samples size was low. Second, in two studies serum levels of omega-3 fatty acid had not been
184
evaluated. Third, only one study scored < 3 on the Jadad scale. Conclusion
185
In conclusion, supplementation with omega-3 fatty acids containing EPA and DHA had no
186
significant effect on insulin plasma level and HOMA-IR in women with PCOS. Due to the
187
small sample size of the included trials, further high-quality RCTs are needed.
188
Acknowledgement
189
AS designed the study. AS, SS-b and KDj, contributed to the literature searches, data
190
extraction and independent reviewing. AS and SS-b performed the statistical analyses and
191
wrote a first draft of the manuscript. SS-b and KD prepared final draft.
192
Funding Sources
193
8
This research received no specific grant from any funding agency, commercial or not-for-
194
profit sectors.
195
Disclosures
196
None.
197 198 199 200 201 202
References
203 1. Spritzer PM (2014) Polycystic ovary syndrome: reviewing diagnosis and management of metabolic disturbances. Arquivos Brasileiros de Endocrinologia & Metabologia 58, 182-187. 2. Lakkakula BVKS, Thangavelu M, Godla UR (2013) Genetic variants associated with insulin signaling and glucose homeostasis in the pathogenesis of insulin resistance in polycystic ovary syndrome: a systematic review. Journal of assisted reproduction and genetics 30, 883-895. 3. Kelley CE, Brown AJ, Diehl AM et al. (2014) Review of nonalcoholic fatty liver disease in women with polycystic ovary syndrome. World J Gastroenterol 20, 14172-14184. 4. Gonzalez F, Kirwan JP, Rote NS et al. (2013) Glucose ingestion stimulates atherothrombotic inflammation in polycystic ovary syndrome. American journal of physiology Endocrinology and metabolism 304, E375-383. 5. Spritzer PM, Lecke SB, Satler F et al. (2015) Adipose tissue dysfunction, adipokines, and low-grade chronic inflammation in polycystic ovary syndrome. Reproduction 149, R219-R227. 6. Phelan N, O'Connor A, Tun TK et al. (2011) Hormonal and metabolic effects of polyunsaturated fatty acids in young women with polycystic ovary syndrome: results from a cross-sectional analysis and a randomized, placebo-controlled, crossover trial. The American journal of clinical nutrition 93, 652-662. 7. Zheng Y, Stener-Victorin E, Ng EH et al. (2015) How does acupuncture affect insulin sensitivity in women with polycystic ovary syndrome and insulin resistance? Study protocol of a prospective pilot study. BMJ open 5, e007757. 8. Kelley CE, Brown AJ, Diehl AM et al. (2014) Review of nonalcoholic fatty liver disease in women with polycystic ovary syndrome. World Journal of Gastroenterology : WJG 20, 14172-14184. 9. Zheng Y, Stener-Victorin E, Ng EHY et al. (2015) How does acupuncture affect insulin sensitivity in women with polycystic ovary syndrome and insulin resistance? Study protocol of a prospective pilot study. BMJ Open 5, e007757. 10. Oner G, Muderris, II (2013) Efficacy of omega-3 in the treatment of polycystic ovary syndrome. Journal of obstetrics and gynaecology : the journal of the Institute of Obstetrics and Gynaecology 33, 289-291.
9
204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230
11. González F, Kirwan JP, Rote NS et al. (2013) Glucose ingestion stimulates atherothrombotic inflammation in polycystic ovary syndrome. American Journal of Physiology-Endocrinology and Metabolism 304, E375-E383. 12. Ardawi MSM, Rouzi AA (2005) Plasma adiponectin and insulin resistance in women with polycystic ovary syndrome. Fertility and sterility 83, 1708-1716. 13. Rafraf M, Mohammadi E, Asghari-Jafarabadi M et al. (2012) Omega-3 fatty acids improve glucose metabolism without effects on obesity values and serum visfatin levels in women with polycystic ovary syndrome. Journal of the American College of Nutrition 31, 361-368. 14. Forouhi N, Shab-Bidar S, Djafarian K (2015) Effect of omega-3 fatty acids supplementation on testosterone levels in women with polycystic ovary syndrome: Meta-analysis of randomized controlled trials. Journal of Nutritional Sciences and Dietetics 1, 165-170. 15. Oner G, Muderris I (2013) Efficacy of omega-3 in the treatment of polycystic ovary syndrome. Journal of Obstetrics and Gynaecology 33, 289-291. 16. Zheng J-S, Huang T, Yang J et al. (2012) Marine N-3 polyunsaturated fatty acids are inversely associated with risk of type 2 diabetes in Asians: a systematic review and meta-analysis. PloS one 7, e44525. 17. Monk JM, Turk HF, Liddle DM et al. (2014) n-3 Polyunsaturated Fatty Acids and Mechanisms to Mitigate Inflammatory Paracrine Signaling in Obesity-Associated Breast Cancer. Nutrients 6, 47604793. 18. Norman G, Faria R, Paton F et al. (2013) The Preferred Reporting Items for Systematic Reviews and Meta-analyses. 19. Jadad AR, Moore RA, Carroll D et al. (1996) Assessing the quality of reports of randomized clinical trials: is blinding necessary? Controlled clinical trials 17, 1-12. 20. Marik PE, Zaloga GP (2004) Meta-analysis of parenteral nutrition versus enteral nutrition in patients with acute pancreatitis. Bmj 328, 1407. 21. Rafraf M, Mohammadi E, Asghari-Jafarabadi M et al. (2012) Omega-3 fatty acids improve glucose metabolism without effects on obesity values and serum visfatin levels in women with polycystic ovary syndrome. Journal of the American College of Nutrition 31, 361-368. 22. Phelan N, O'Connor A, Kyaw Tun T et al. (2011) Hormonal and metabolic effects of polyunsaturated fatty acids in young women with polycystic ovary syndrome: results from a crosssectional analysis and a randomized, placebo-controlled, crossover trial. The American journal of clinical nutrition 93, 652-662. 23. ESHRE TR, Group A-SPCW (2004) Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertility and sterility 81, 19-25. 24. Cussons AJ, Watts GF, Mori TA et al. (2009) Omega-3 fatty acid supplementation decreases liver fat content in polycystic ovary syndrome: a randomized controlled trial employing proton magnetic resonance spectroscopy. The Journal of clinical endocrinology and metabolism 94, 3842-3848. 25. Mohammadi E, Rafraf M, Farzadi L et al. (2012) Effects of omega-3 fatty acids supplementation on serum adiponectin levels and some metabolic risk factors in women with polycystic ovary syndrome. Asia Pacific journal of clinical nutrition 21, 511-518. 26. Vargas ML, Almario RU, Buchan W et al. (2011) Metabolic and endocrine effects of long-chain versus essential omega-3 polyunsaturated fatty acids in polycystic ovary syndrome. Metabolism: clinical and experimental 60, 1711-1718. 27. Abbott D, Dumesic D, Franks S (2002) Developmental origin of polycystic ovary syndrome-a hypothesis. Journal of Endocrinology 174, 1-5. 28. Abbott DH, Bacha F (2013) Ontogeny of polycystic ovary syndrome and insulin resistance in utero and early childhood. Fertility and sterility 100, 2-11. 29. Magee P, Pearson S, Whittingham-Dowd J et al. (2012) PPARγ as a molecular target of EPA antiinflammatory activity during TNF-α-impaired skeletal muscle cell differentiation. The Journal of nutritional biochemistry 23, 1440-1448.
10
231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280
30. Kabir M, Skurnik G, Naour N et al. (2007) Treatment for 2 mo with n− 3 polyunsaturated fatty acids reduces adiposity and some atherogenic factors but does not improve insulin sensitivity in women with type 2 diabetes: a randomized controlled study. The American journal of clinical nutrition 86, 1670-1679. 31. Mostad IL, Bjerve KS, Bjorgaas MR et al. (2006) Effects of n− 3 fatty acids in subjects with type 2 diabetes: reduction of insulin sensitivity and time-dependent alteration from carbohydrate to fat oxidation. The American journal of clinical nutrition 84, 540-550. 32. Tahvonen RL, Schwab US, Linderborg KM et al. (2005) Black currant seed oil and fish oil supplements differ in their effects on fatty acid profiles of plasma lipids, and concentrations of serum total and lipoprotein lipids, plasma glucose and insulin. The Journal of nutritional biochemistry 16, 353-359. 33. Navas-Carretero S, Pérez-Granados AM, Schoppen S et al. (2009) An oily fish diet increases insulin sensitivity compared to a red meat diet in young iron-deficient women. British journal of nutrition 102, 546-553. 34. Fakhrzadeh H, Ghaderpanahi M, Sharifi F et al. (2010) The effects of low dose n-3 fatty acids on serum lipid profiles and insulin resistance of the elderly: a randomized controlled clinical trial. Int J Vitam Nutr Res 80, 107-116. 35. Akinkuolie AO, Ngwa JS, Meigs JB et al. (2011) Omega-3 polyunsaturated fatty acid and insulin sensitivity: a meta-analysis of randomized controlled trials. Clinical nutrition (Edinburgh, Scotland) 30, 702-707.
281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301
Table 1. Characteristics of included studies Study’s first author
Year
Country
Study design
Participants, mean age
EPA/DHA dose
Mohammadi et al.,
2012
Iran
DB
N=22 women, I = 27.7 P = 27.3
1.2 g
Cussons et al.,
2009
Australia
DB
2011
USA
Sample size
Jadad score
8
I = 30 P = 31
4
8
I = 25 P = 25
2
3.32 g N=22 women, I = 32.7 P =32.7
Vargas et al.,
Duration (weeks)
DB
3.6 g N=22 women, I = 6 I = 17 3 31.7 P = 17 P = 28.9 I : Intervention; P: Placebo; EPA :Eicosapentaenoic acid; DHA :Docosahexaenoic acid; PCOS : Polycystic ovarian Syndrome; DB: double blind
302 303 304 305
11
306 Additional records identified through other sources (n=2)
Records identified thorough PubMed and Scopus databases (n=1200)
307 308 309
Records after duplicates removed
310
(n=808)
311 Records excluded by screening title/abstract (n=802)
312 313
Full-text articles assessed for eligibility (n=6)
314 3 were excluded Studies without sufficient data or placebo group and overlapped study
315 316
Studies included in quantitative and synthesis (meta-analysis)
317
(n=3)
318 319 320 321 322 323 324
Figure 1. Flow diagram of study 12
325
Author (year)
MD (95%CI) Weight
326
Figure2. Effect of omega-3 fatty acid supplementation on insulin plasma level in women
327
with polycystic ovarian
328 329 330 331
332
Figure3. Effect of omega-3 fatty acid supplementation on HOMA-IR in women with
333
polycystic ovarian
334 335 13
Author (year)
MD (95%CI) Weight
336 337
14
  • Author : Jennifer Chiaverini
  • Release Date : 14 May 2019
  • Publisher : HarperCollins
  • Categories : Fiction
  • Pages : 640 pages
  • ISBN 13 : 9780062841117
  • ISBN 10 : 0062841114
  • Format : PDF, ePUB, KF8, PDB, MOBI, AZW

Synopsis : Resistance Women written by Jennifer Chiaverini, published by HarperCollins which was released on 14 May 2019. Download Resistance Women Books now! Available in PDF, EPUB, Mobi Format.One of BookBub's best historical novels of the year and Oprah magazine's buzziest books of the month. From the New York Times bestselling author of Mrs. Lincoln’s Dressmaker, an enthralling historical saga that recreates the danger, romance, and sacrifice of an era and brings to life one courageous, passionate American—Mildred Fish Harnack—and her circle of women friends who waged a clandestine battle against Hitler in Nazi Berlin. After Wisconsin graduate student Mildred Fish marries brilliant German economist Arvid Harnack, she accompanies him to his German homeland, where a promising future awaits. In the thriving intellectual culture of 1930s Berlin, the newlyweds create a rich new life filled with love, friendships, and rewarding work—but the rise of a malevolent new political faction inexorably changes their fate. As Adolf Hitler and his Nazi Party wield violence and lies to seize power, Mildred, Arvid, and their friends resolve to resist. Mildred gathers intelligence for her American contacts, including Martha Dodd, the vivacious and very modern daughter of the US ambassador. Her German friends, aspiring author Greta Kuckoff and literature student Sara Weitz, risk their lives to collect information from journalists, military officers, and officials within the highest levels of the Nazi regime. For years, Mildred’s network stealthily fights to bring down the Third Reich from within. But when Nazi radio operatives detect an errant Russian signal, the Harnack resistance cell is exposed, with fatal consequences. Inspired by actual events, Resistance Women is an enthralling, unforgettable story of ordinary people determined to resist the rise of evil, sacrificing their own lives and liberty to fight injustice and defend the oppressed.

Resistance Women PDF Free Download

Resistance Women Pdf Free Download Free

Resistance Women PDF Free Download

Resistance Women Pdf free. download full

A circle with its left hemisphere filled. Visual Adjustments. Collapse sidebar. A circle with a left pointing chevron. THE RUNAWAY BESTSELLER THE SYMPTOMS OF FUTURE SHOCK ARE WITH US NOW. THIS BOOK CAN HELP US SURVIVE OUR COLLISION WITH TOMORROW. IFurure Sock offlep. 0.25x 0.5x 0.75x 1.0x 1.25x 1.5x 1.75x 2x. Understand the benefits to stability ball and resistance band training. Learn proper positioning, range of motion, and exercise tips for bodyweight, stability ball, and resistance band exercises for the upper body, lower body, and core. Understand the benefits of incorporating barbells and dumbbells into your workout program. 142KB Sizes 0 Downloads 35 Views. Recommend Documents. The hypertriglyceridemic waist phenotype among women. Report 'W08-P-015 Hypertriglyceridemic waist as a simple clinical parameter for insulin resistance in women' Your name. Using ProSource Resistance Tubes, discontinue use & consult your physician. Please use caution & carefully follow all exercise instructions and use proper tech- nique when using our Resistance Tubes. Always modify exercises as needed for your fitness level. If you have any questions, concerns or comments about ProSource Resistance Tubes.