INTRODUCTION AND AIM Black South Africans are experiencing an increase in the prevalence of cardiovascular disease (CVD). Fibrinogen functionality, including total and gamma prime (y’) fibrinogen concentration, as well as fibrin network structure, play an important role in CVD development and events. Several genetic and environmental factors influence fibrinogen functionality, and in turn, known CVD risk factors associated with total and y’ fibrinogen concentration have also been associated with altered fibrin clot structure. However, the main body of evidence regarding the role of fibrinogen functionality in CVD is based on studies conducted in white ethnicities and/or in vitro. The main aim of this study was, therefore, to determine the relationship between fibrinogen functionality and CVD in black South Africans in a plasma setting. Since there is greater genetic diversity in Africans than in non-black ethnicities, it was also our objective to investigate the influence of genetic polymorphisms in determining fibrinogen synthesis and plasma clot properties, and to determine possible gene-environment interactions altering clot properties. PARTICIPANTS AND METHODS The South African arm of the Prospective Urban and Rural Epidemiology (PURE) study included 2010 apparently healthy black men and women between the ages of 35 and 65 years, residing in rural or urban settlements. Blood samples were collected from the participants during a 12-week period in 2005. The following variables were analysed: total and y’ fibrinogen concentration, CVD risk factors and genetic polymorphisms in the fibrinogen and Factor XIII genes as well as turbidimetric analysis of clot formation and lysis (expressed as clot lysis time (CLT)). RESULTS Increased plasma levels of both total (largest contribution of 33%) and y’ fibrinogen were associated with increased fibre diameter while y’/total fibrinogen ratio had the opposite effect. The rate of lateral aggregation of fibrin fibres (slope) increased with an increase in total fibrinogen concentration, but not fibrinogen y’. Increasing fibrinogen y’ concentration was associated with longer CLTs and was the largest contributor to its variance (12%). Increased total and y’ fibrinogen were significantly associated with increased waist circumference, body mass index, C-reactive protein (CRP), glycosylated haemoglobin, metabolic syndrome (MetS) and low high-density lipoprotein (HDL) cholesterol levels. Furthermore, the association of fibrinogen y’ with these CVD risk factors was independent of total fibrinogen levels. C-reactive protein was the largest contributor to variance in fibrinogen y’ levels and y’/total fibrinogen ratio (apart from total fibrinogen). We observed significant associations between single nucleotide polymorphisms (SNPs) at rs1049636 and rs2070011 loci and increased total and y’ fibrinogen levels, respectively. Only SNP rs1800787 was associated with clot properties (increased maximum absorbance). Significant gene-environment interactions were observed between SNPs rs2227385, rs1800787, rs1800788, rs4220 and rs5985 and total and/or y’ fibrinogen levels in determining clot properties. The CVD risk factors age, MetS, CRP, HDL-cholesterol and homocysteine associated significantly with clot properties, independent of total and/or y’ fibrinogen plasma concentration. CONCLUSION The results of this thesis provide several novel insights relevant to this research field. Plasma y’ fibrinogen concentration and y’ ratio were found to be associated with altered clot properties in a plasma setting, and are also influenced by CVD risk factors other than fibrinogen. The associations between SNPs, total and y’ fibrinogen and clot properties differ somewhat from evidence reported in white populations. Significant gene-environment interactions between SNPs and total and y’ fibrinogen in determining clot properties existed and had opposing effects, i.e. both prothrombotic and antithrombotic, suggesting that the influence of genetic factors on fibrinogen should focus not only on concentration, but also on functionality. Cardiovascular disease risk factors also influence clot properties in vivo, through mechanisms independent of total and/or y’ fibrinogen concentration. / PhD (Nutrition), North-West University, Potchefstroom Campusm, 2015

INTRODUCTION AND AIM Black South Africans are experiencing an increase in the prevalence of cardiovascular disease (CVD). Fibrinogen functionality, including total and gamma prime (y’) fibrinogen concentration, as well as fibrin network structure, play an important role in CVD development and events. Several genetic and environmental factors influence fibrinogen functionality, and in turn, known CVD risk factors associated with total and y’ fibrinogen concentration have also been associated with altered fibrin clot structure. However, the main body of evidence regarding the role of fibrinogen functionality in CVD is based on studies conducted in white ethnicities and/or in vitro. The main aim of this study was, therefore, to determine the relationship between fibrinogen functionality and CVD in black South Africans in a plasma setting. Since there is greater genetic diversity in Africans than in non-black ethnicities, it was also our objective to investigate the influence of genetic polymorphisms in determining fibrinogen synthesis and plasma clot properties, and to determine possible gene-environment interactions altering clot properties. PARTICIPANTS AND METHODS The South African arm of the Prospective Urban and Rural Epidemiology (PURE) study included 2010 apparently healthy black men and women between the ages of 35 and 65 years, residing in rural or urban settlements. Blood samples were collected from the participants during a 12-week period in 2005. The following variables were analysed: total and y’ fibrinogen concentration, CVD risk factors and genetic polymorphisms in the fibrinogen and Factor XIII genes as well as turbidimetric analysis of clot formation and lysis (expressed as clot lysis time (CLT)). RESULTS Increased plasma levels of both total (largest contribution of 33%) and y’ fibrinogen were associated with increased fibre diameter while y’/total fibrinogen ratio had the opposite effect. The rate of lateral aggregation of fibrin fibres (slope) increased with an increase in total fibrinogen concentration, but not fibrinogen y’. Increasing fibrinogen y’ concentration was associated with longer CLTs and was the largest contributor to its variance (12%). Increased total and y’ fibrinogen were significantly associated with increased waist circumference, body mass index, C-reactive protein (CRP), glycosylated haemoglobin, metabolic syndrome (MetS) and low high-density lipoprotein (HDL) cholesterol levels. Furthermore, the association of fibrinogen y’ with these CVD risk factors was independent of total fibrinogen levels. C-reactive protein was the largest contributor to variance in fibrinogen y’ levels and y’/total fibrinogen ratio (apart from total fibrinogen). We observed significant associations between single nucleotide polymorphisms (SNPs) at rs1049636 and rs2070011 loci and increased total and y’ fibrinogen levels, respectively. Only SNP rs1800787 was associated with clot properties (increased maximum absorbance). Significant gene-environment interactions were observed between SNPs rs2227385, rs1800787, rs1800788, rs4220 and rs5985 and total and/or y’ fibrinogen levels in determining clot properties. The CVD risk factors age, MetS, CRP, HDL-cholesterol and homocysteine associated significantly with clot properties, independent of total and/or y’ fibrinogen plasma concentration. CONCLUSION The results of this thesis provide several novel insights relevant to this research field. Plasma y’ fibrinogen concentration and y’ ratio were found to be associated with altered clot properties in a plasma setting, and are also influenced by CVD risk factors other than fibrinogen. The associations between SNPs, total and y’ fibrinogen and clot properties differ somewhat from evidence reported in white populations. Significant gene-environment interactions between SNPs and total and y’ fibrinogen in determining clot properties existed and had opposing effects, i.e. both prothrombotic and antithrombotic, suggesting that the influence of genetic factors on fibrinogen should focus not only on concentration, but also on functionality. Cardiovascular disease risk factors also influence clot properties in vivo, through mechanisms independent of total and/or y’ fibrinogen concentration. / PhD (Nutrition), North-West University, Potchefstroom Campusm, 2015

INTRODUCTION AND AIM - Cardiovascular disease is globally a major risk factor for morbidity and mortality. It is caused by various factors, one of which is an abnormal haemostatic process. Fibrinogen is a haemostatic factor that is considered to be an independent risk factor for cardiovascular disease. Elevated fibrinogen can be caused by environmental and genetic factors which increase the risk of the occurrence of thrombosis. The fibrinogen y' chain, which is one of the three chains of fibrinogen, has two different variants, the yA and y’. The presence of the fibrinogen y’ chain has been associated with thrombotic disorders. Many studies have investigated the fibrinogen variables in Caucasian individuals, but only a few such studies have been conducted on non-Caucasian individuals. The genetic diversity of ethnic groups differs and could cause differences in the fibrinogen variables between these groups. Fibrinogen is known to increase with age; therefore to explain changes over time in fibrinogen concentrations it was also important to investigate whether genetic determinants and possible gene–environment interactions influenced fibrinogen over time. In this study the main aim was to determine the change in the fibrinogen variables over a five-year period within a black South African cohort subdivided according to genotypes associated with fibrinogen variables, and to determine whether the observed changes were modulated by environmental factors. PARTICIPANTS AND METHODS - Data [baseline (n=2010) and follow-up (n=1288)] were collected in the Prospective Urban and Rural Epidemiology (PURE) study during 2005 and 2010 from apparently healthy black men and women aged between 35 and 65 years and residing in rural or urban settlements. Experimental methods included analysis of fibrinogen and fibrinogen y’ concentrations, single nucleotide polymorphisms (SNPs) and determination of environmental factors associated with the fibrinogen variables. RESULTS - The fibrinogen variables increased significantly from 2005 to 2010 in both the rural and urban participants, as well as in both men and women. The major environmental factors that affected the fibrinogen variables were C-reactive protein (CRP), interleukin-6 (IL-6), body mass index (BMI), glycated haemoglobin (HbA1c), age, blood lipids, human immunodeficiency virus (HIV) and tobacco use. Fibrinogen increased consistently from 2005 to 2010 in the respective genotypes of all SNPs analysed, except in the FGG 9340 T>C homozygous mutant carriers. Fibrinogen y’ also increased in general in most genotypes from 2005 to 2010, except in the FGG 10034 C>T mutant allele carriers, where a decrease was observed. It was determined that CRP was the only environmental factor that influenced the change in fibrinogen over time and that FGG 10034 C>T was the only SNP that influenced the change in fibrinogen y’ over the five years. Four gene–environment interactions also influenced fibrinogen on a cross-sectional level, i.e. FGA 2224 G>A with age, FGB Arg448Lys with HIV status, FGB 1643 C>T with urbanisation and FGB 1038 G>A with HbA1c. Only the FGG 9340 T>C with HbA1c interaction was found to predict change in fibrinogen concentrations over the five years. CONCLUSION - Both environmental and genetic factors significantly influenced the fibrinogen variables cross-sectionally as well as prospectively. It was clear that the influence of the environmental factors was mediated by genetic polymorphisms and vice versa, as can be seen by the gene–environment interactions found in this study. An important finding of this study was that the interaction of HbA1c with two SNPs on fibrinogen variables may explain the known inconsistent relationship found between fibrinogen concentrations and diabetes. / MSc (Dietetics), North-West University, Potchefstroom Campus, 2014

INTRODUCTION AND AIM - Cardiovascular disease is globally a major risk factor for morbidity and mortality. It is caused by various factors, one of which is an abnormal haemostatic process. Fibrinogen is a haemostatic factor that is considered to be an independent risk factor for cardiovascular disease. Elevated fibrinogen can be caused by environmental and genetic factors which increase the risk of the occurrence of thrombosis. The fibrinogen y' chain, which is one of the three chains of fibrinogen, has two different variants, the yA and y’. The presence of the fibrinogen y’ chain has been associated with thrombotic disorders. Many studies have investigated the fibrinogen variables in Caucasian individuals, but only a few such studies have been conducted on non-Caucasian individuals. The genetic diversity of ethnic groups differs and could cause differences in the fibrinogen variables between these groups. Fibrinogen is known to increase with age; therefore to explain changes over time in fibrinogen concentrations it was also important to investigate whether genetic determinants and possible gene–environment interactions influenced fibrinogen over time. In this study the main aim was to determine the change in the fibrinogen variables over a five-year period within a black South African cohort subdivided according to genotypes associated with fibrinogen variables, and to determine whether the observed changes were modulated by environmental factors. PARTICIPANTS AND METHODS - Data [baseline (n=2010) and follow-up (n=1288)] were collected in the Prospective Urban and Rural Epidemiology (PURE) study during 2005 and 2010 from apparently healthy black men and women aged between 35 and 65 years and residing in rural or urban settlements. Experimental methods included analysis of fibrinogen and fibrinogen y’ concentrations, single nucleotide polymorphisms (SNPs) and determination of environmental factors associated with the fibrinogen variables. RESULTS - The fibrinogen variables increased significantly from 2005 to 2010 in both the rural and urban participants, as well as in both men and women. The major environmental factors that affected the fibrinogen variables were C-reactive protein (CRP), interleukin-6 (IL-6), body mass index (BMI), glycated haemoglobin (HbA1c), age, blood lipids, human immunodeficiency virus (HIV) and tobacco use. Fibrinogen increased consistently from 2005 to 2010 in the respective genotypes of all SNPs analysed, except in the FGG 9340 T>C homozygous mutant carriers. Fibrinogen y’ also increased in general in most genotypes from 2005 to 2010, except in the FGG 10034 C>T mutant allele carriers, where a decrease was observed. It was determined that CRP was the only environmental factor that influenced the change in fibrinogen over time and that FGG 10034 C>T was the only SNP that influenced the change in fibrinogen y’ over the five years. Four gene–environment interactions also influenced fibrinogen on a cross-sectional level, i.e. FGA 2224 G>A with age, FGB Arg448Lys with HIV status, FGB 1643 C>T with urbanisation and FGB 1038 G>A with HbA1c. Only the FGG 9340 T>C with HbA1c interaction was found to predict change in fibrinogen concentrations over the five years. CONCLUSION - Both environmental and genetic factors significantly influenced the fibrinogen variables cross-sectionally as well as prospectively. It was clear that the influence of the environmental factors was mediated by genetic polymorphisms and vice versa, as can be seen by the gene–environment interactions found in this study. An important finding of this study was that the interaction of HbA1c with two SNPs on fibrinogen variables may explain the known inconsistent relationship found between fibrinogen concentrations and diabetes. / MSc (Dietetics), North-West University, Potchefstroom Campus, 2014