This paper provides a broad overview of the epidemiological and genetical aspects of common multifactorial diseases in man with focus on three well-studied ones, namely, coronary heart disease (CHD), essential hypertension (EHYT) and diabetes mellitus (DM). In contrast to mendelian diseases, for which a mutant gene either in the heterozygous or homozygous condition is generally sufficient to cause disease, for most multifactorial diseases, the concepts of 'genetic susceptibility' and 'risk factors' are more appropriate. For these diseases, genetic susceptibility is heterogeneous. The well-studied diseases such as CHD permit one to conceptualize the complex relationships between genotype and phenotype for chronic multifactorial diseases in general, namely that allelic variations in genes, through their products interacting with environmental factors, contribute to the quantitative variability of biological risk factor traits and thus ultimately to disease outcome. Two types of such allelic variations can be distinguished, namely those in genes whose mutant alleles have (i) small to moderate effects on the risk factor trait, are common in the population (polymorphic alleles) and therefore contribute substantially to the variability of biological risk factor traits and (ii) profound effects, are rare in the population and therefore contribute far less to the variability of biological risk factor traits. For all the three diseases considered in this review, a positive family history is a strong risk factor. CHD is one of the major contributors to mortality in most industrialized countries. Evidence from epidemiological studies, clinical correlations, genetic hyperlipidaemias etc., indicate that lipids play a key role in the pathogenesis of CHD. The known lipid-related risk factors include: high levels of low density lipoprotein cholesterol, low levels of high density lipoprotein cholesterol, high apoB levels (the major protein fraction of the low density lipoprotein particles) and elevated levels of Lp(a) lipoprotein. Among the risk factors which are not related to lipids are: high levels of homocysteine, low activity of paraoxonase and possibly also elevated plasma fibrinogen levels. In addition to the above, hypertension, diabetes and obesity (which themselves have genetic determinants) are important risk factors for CHD. Among the environmental risk factors are: high dietary fat intake, smoking, stress, lack of exercise etc. About 60% of the variability of the plasma cholesterol is genetic in origin. While a few genes have been identified whose mutant alleles have large effects on this trait (e.g., LDLR, familial defective apoB-100), variability in cholesterol levels among individuals in most families is influenced by allelic variation in many genes (polymorphisms) as well as environmental exposures. A proportion of this variation can be accounted for by two alleles of the apoE locus that increase (ε4) and decrease (ε2) cholesterol levels, respectively. A polymorphism at the apoB gene (XbaI) also has similar effects, but is probably not mediated through lipids. High density lipoprotein cholesterol levels are genetically influenced and are related to apoA1 and hepatic lipase (LIPC) gene functions. Mutations in the apoA1 gene are rare and there are data which suggest a role of allelic variation at or linked LIPC gene in high density lipoprotein cholesterol levels. Polymorphism at the apoA1-C3 loci is often associated with hypertriglyceridemia. The apo(a) gene which codes for Lp(a) is highly polymorphic, each allele determining a specific number of multiple tandem repeats of a unique coding sequence known as Kringle 4. The size of the gene correlates with the size of the Lp(a) protein. The smaller the size of the Lp(a) protein, the higher are the Lp(a) levels. Hyperhomocyst(e)inemia is a risk factor for myocardial infarction, stroke and peripheral vascular disease, but the precise nature and intensity of this association, the biochemical mechanisms involved and the role of environmental factors remain to be fully elucidated. Recently, it has been suggested that polymorphisms in genes that code for paraoxonase may need to be added to the list of genetic risk factors for CHD. There are suggestions that high plasma fibrinogen levels (which is exacerbated by smoking which also lowers high density lipoprotein cholesterol levels) may constitute yet another risk factor for CHD. Essential hypertension (EHYT) affects some 10-25% of the people of the industrial world. Its clinical relevance stems from the fact that it is one of the major risk factors for cardiovascular and renal diseases, especially, stroke, coronary heart disease and end-stage renal disease. The role of genetic factors in EHYT is clearly indicated by family studies in which correlations in blood pressure levels have been studied. The variations in the range and magnitude of these correlations however suggest that other, environmental factors must play an important role and which vary from individual to individual and population to population. No major genes controlling blood pressure have been identified. However, during the past five years or so, linkage and association studies have shown that there are at least three gene loci, polymorphism at which may contribute to EHYT: these include the AGT, AT1 and ACE genes. Additionally, the molecular basis of three rare mendelian disorders associated with hypertension, namely those involved in glucocorticosteroid-remediable aldosteronism (GRA), Liddle syndrome and apparent mineralocorticosteroid excess (AME) have been delineated. On the basis of clinical phenotypes, four types of diabetes mellitus are distinguished, of which insulin-dependent diabetes mellitus (IDDM) and non-insulin-dependent diabetes mellitus (NIDDM) have been the subject of extensive studies. IDDM is a group of heterogeneous diseases probably resulting from exposure to some environmental agent(s) in those individuals with a genetically-determined susceptibility. IDDM is the result of the destruction of insulin-producing β-cells of the pancreas, principally by immunoglogically-mediated (autoimmune) mechanisms. The major defined risk factor is genetic susceptibility: apart from IDDM1 (linked to the HLA complex) and IDDM2 (in the insulin gene region) at least 10 other genes are involved, mutations at which cause susceptibility to IDDM. There is recent evidence for the possible involvement of an endogenous retrovirus in the aetiology of acute onset IDDM. NIDDM is a very common disease and its prevalence varies in different populations. As in the case of IDDM, its major determinant is genetic susceptibility. Compared to IDDM, the concordance rates in monozygotic twins and risks to first-degree relatives are higher. With the exception of MODY subtype with earlier onset, most cases have onset in middle or late life. The known geographical variations in the prevalence and studies of migrant populations suggest that enviromental factors might also be important. The number of genes mutations at which cause susceptibility to NIDDM is not yet known and so far, one putative major gene locus has recently been identified in a Mexican-American population. Several candidate genes are currently being investigated. The available data indicate that some of the genes act through inherited susceptibility to insulin resistant and to decreased capacity for insulin secretion. Rare forms are due to dominant mutations i.e., the MODY diabetes and rarer still are forms due to the production of abnormal insulin due to mutations in the insulin gene itself. Finally, a small proportion of diabetes may be due to mutations in the mitochondrial genome. The attributes, risk factors and interrelationships between the three diseases considered in this review clearly show that the task of using this information for reliably predicting the risk of any of these diseases is formidable, even for a scenario of no radiation exposures, not to mention radiation scenarios. Nonetheless, these data provide a useful framework for developing models aimed at quantifying the response to these diseases to an increase in mutation rate due to radiation. One such model is discussed in a later paper of this series. (C) 1999 Elsevier Science B.V.
- Chronic multifactorial disease
- Coronary heart disease
- Diabetes mellitus
- Essential hypertension