In their meta-analysis of 27 published studies, D'Mello et al 1 show that shortened leukocyte telomere length (LTL) is associated with 3 primary end points: myocardial infarction, stroke, and type 2 diabetes mellitus. The meta-analysis and its findings raise several fundamental issues that are worth considering. After discussing the major findings and limitations, we focus on 3 central themes: the reliability of LTL measurements, the biological meaning of the association of LTL with cardio-metabolic outcomes, and future directions of telomere research with respect to cardiovascular disease (CVD) and longevity in humans.
Article see p 82The underlying reason for meta-analysis is usually lack of consensus across studies. This clearly applies to the field of telomere epidemiology, which is awash with conflicting findings not only in the context of CVD but also cancer and longevity. The meta-analysis of D'Mello et al shows a significant association of LTL with each of the 3 primary end points, but the test for heterogeneity across the studies was significant for each disease. The authors suggest that ethnicity or perhaps demography, which is often associated with ethnicity, might explain some disagreements in findings across populations (and studies). Notably, however, 26 of the 27 studies analyzed across the 3 primary disease end points had odds ratios >1, indicating that the observed heterogeneity resulted from varying magnitudes of a positive association with disease and not from some studies showing inverse associations. The subgroup analysis in Figure 3 of the D'Mello paper suggests that the racial or ethnic group with the highest prevalence of the specific disease showed the smallest association with LTL (Asians for stroke, Hispanics and African Americans for diabetes mellitus). It is unclear why this would be so, unless the higher prevalence of disease in these groups was caused by influential ethnic-related determinants independent of the basic biological and heritable influences of telomere length. The authors were not able to get further data on race and ethnic group from the contributing studies to adequately address these important potentially confounding variables. The number of studies available in some of the racial and ethnic groups was simply too few to draw reliable conclusions as to their influence on the heterogeneity of the estimated disease risks. Also, the inverse association seen in the meta-analysis between sample size and odds ratios estimates (ie, the smaller the study, the more likely the odds ratios estimates were to be elevated) is consistent with the likely publication bias suggested by the authors. Smaller studies with null results are probably unpublished as demonstrated by both Haycock et al and D'Mello et al.
Reliability of LTL MeasurementsThe reliability of LTL measurements and sample size are closely linked with respect to findings and conclusions because less reliable LTL measurements require larger samples to test associations and hypotheses. With an interassay coefficient of v...