The Journal of Nutrition
Total Antioxidant Performance Is Associated
with Diet and Serum Antioxidants in
Participants of the Diet and Physical Activity
Substudy of the Jackson Heart Study1,2
Sameera A. Talegawkar,3Giangiacomo Beretta,4Kyung-Jin Yeum,5Elizabeth J. Johnson,5
Teresa C. Carithers,6Herman A. Taylor Jr,7Robert M. Russell,5and Katherine L. Tucker5*
3Division of Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore,
MD 21025;4Department of Pharmaceutical Sciences, Pietro Pratesi, Faculty of Pharmacy, University of Milan, 20133 Milan, Italy;5Jean
Mayer USDA Human Nutrition Research Center on Aging at Tufts University, Boston, MA 02111;6Department of Family and Consumer
Sciences, University of Mississippi, University, MS 38677; and7The Jackson Heart Study, University of Mississippi Medical Center,
Jackson, MS 39216
Total antioxidant performance (TAP) measures antioxidant capacities in both hydrophilic and lipophilic compartments of
serum and interactions known to exist between them. Our objective was to assess TAP levels in a subset of Jackson
Heart Study (JHS) participants and to examine associations with dietary and total (diet + supplement) intakes of
a-tocopherol, g-tocopherol (diet only), b-carotene, vitamin C, fruit, vegetables, and nuts, and serum concentrations of
a-tocopherol, g-tocopherol, and b-carotene. We conducted a cross-sectional analysis of 420 (mean age 61 y; 254 women)
African American men and women participating in the Diet and Physical Activity Sub-Study of the JHS in Jackson,
Mississippi. In multivariate-adjusted models, we observed positive associations between total a-tocopherol, total and
dietary b-carotene, and total vitamin C intakes and TAP levels (P-trend , 0.05). Positive associations were also observed
for vegetable, fruit, and total fruit and vegetable intakes (P-trend , 0.05). For serum antioxidant nutrients, a-tocopherol but
not b-carotene was associated with serum TAP levels. There were inverse associations for serum g-tocopherol and TAP
levels. Associations for a-tocopherol were seen at intake levels much higher than the current Recommended Dietary
Allowance. It may, therefore, be prudent to focus on increasing consumption of fruit, vegetables, nuts, and seeds to
increase total antioxidant capacity.J. Nutr. 139: 1964–1971, 2009.
Oxidative stress is an imbalance between the production of
reactive oxygen radicals and the ability of the organism’s natural
protective mechanisms to cope with these radicals and to prevent
adverse effects (1). Cells in the body are exposed to reactive
oxygen species under normal circumstances via the leakage of
electrons from the electron transport chain, phagocytic cells, and
endogenous enzyme systems (2). The oxidation of lipids, nucleic
acids, or protein by these reactive oxygen species is thought to be
associated with the etiology of several age-related chronic
diseases, including cancer (3), cardiovascular disease (4), cataract
(5), and age-related macular degeneration (6). These chronic
diseases account for a high percentage of morbidity and mortality
and preventing them is a major public health priority.
Arrays of defense systems protect the body from the
deleterious effects of oxidative stress. These include antioxidant
enzymes and radical-scavenging antioxidants (7). Antioxidant
nutrients such as vitamin E, carotenoids, and fruits and
vegetables rich in such antioxidants have been associated with
a lower risk of diseases caused by oxidative stress (8–10).
Whereas individual actions of antioxidants have been reported,
a large number of studies have indicated that cooperative/
synergistic interactions exist among antioxidants in plasma (11).
Therefore, studying the overall antioxidant status may be more
biologically relevant than studying a single antioxidant (12). A
relatively recent method called total antioxidant performance
(TAP),8developed by Aldini et al. (13) and validated by Beretta
N01-HC-95172 that were provided by the National Heart, Lung, and Blood
Institute and the National Center for Minority Health and Health Disparities and
by the USDA, Agricultural Research Service no. 6251-53000-003-00D and n.
Carithers, H. A. Taylor Jr, R. M. Russell, and K. L. Tucker, no conflicts of interest.
* To whom correspondence should be addressed. E-mail: katherine.tucker@
8Abbreviationsused: BODIPY 581/591,4, 4-difluoro-5-(4-phenyl-1,3-butadienyl)-
4-bora-3a,4a-diaza-s-indacene-3-undecanoic acid; DPASS, Diet and Physical
Activity Sub-Study; JHS, Jackson Heart Study; ORAC, oxygen radical absorbance
capacity assay; TAP, total antioxidant performance.
0022-3166/08 $8.00 ã 2009 American Society for Nutrition.
Manuscript received March 27, 2009. Initial review completed May 1, 2009. Revision accepted August 6, 2009.
First published online August 26, 2009; doi:10.3945/jn.109.107870.
et al. (14), measures not only antioxidant capacity in both the
hydrophilic and lipophilic compartments of the biological
system, but also their synergistic/ cooperative interactions.
Given the potential for nutrients and foods to contribute to
the prevention of oxidative stress-associated chronic diseases
and the unique ability of TAP to measure total antioxidant
status, the objectives of our study were to: 1) measure serum
antioxidant capacity using the TAP assay in a subset of Jackson
Heart Study (JHS) participants; 2) examine associations between
dietary and total intakes of a-tocopherol, g-tocopherol (diet
only), b-carotene, vitamin C, vegetable, fruit and nut intake, and
TAP levels; and 3) examine associations between serum a- and
g-tocopherol, b-carotene, and TAP levels.
Participants and Methods
Study population. The men and women in this cross-sectional
analysis were participants of the Diet and Physical Activity Sub-
Study (DPASS) of the JHS. The JHS is a single-site prospective
epidemiological investigation of cardiovascular disease among
African Americans from the Jackson, Mississippi metropolitan
area. A detailed description of the original study has been
published elsewhere (15).
Study sample selection. A subset of participants (n = 499)
from the JHS cohort (n = 5301) was selected for the JHS DPASS.
As participants were enrolled in the JHS, investigators recruited
participants for DPASS to include an equal number of men and
women from younger (34–64 y) and older ($65 y) age groups,
from lower and higher socioeconomic status, and from lower
and higherphysical activity groups. Alleligible participants were
invited to be part of DPASS until each of the enrollment strata
were filled. The aim of DPASS was to provide data for validation
of the diet and physical activity instruments used for the entire
cohort of the JHS.
Dietary assessment. The Lower Mississippi Delta Nutrition
Intervention Research Initiative conducted a telephone survey in
the Delta region to collect representative dietary data using 24-h
dietary recalls. These data were used to develop a new FFQ
designed for use in the LMD region. Details regarding develop-
ment of this regional FFQ are available elsewhere (16). This
FFQ, called the Delta NIRI FFQ (283 items), and its shortened
version, the Delta NIRI JHS FFQ (158 items), which was
specifically developed for use in the JHS, were then used as
dietary assessment tools in the DPASS. We have previously
validated both FFQ against the mean of 4 24-h recalls (17),
serum tocopherols (18), and carotenoids (19).
Laboratory analyses. Participants provided blood samples on
the day of the baseline clinic interview, which took place on the
day of administration of the short FFQ. Blood samples from
fasting (12 h) participants were collected in vacutainer tubes and
centrifuged at 3000 3 g for 10 min at 48C. Samples were frozen at
2708C until analyzed. Serum TAP was determined by the method
first developed by Aldini et al. (13) to measure total antioxidant
capacity in both the hydrophilic and lipophilic compartments of
serum and validated by Beretta et al. (14) for the application to
high throughput studies. This method measures the rate of
oxidation of 4, 4-difluoro-5-(4-phenyl-1, 3-butadienyl)-4-bora-
3a,4a-diaza-s-indacene-3-undecanoic acid (BODIPY 581/591), a
lipid-soluble fluorescent probe, and uses the lipid-soluble
Oxidation is determined by monitoring the appearance of green
fluorescence of the oxidation product of BODIPY (lex= 500 nm,
lem= 520 nm) using a 1420 multilabel counter (Wallac Victor 2,
Perkin Elmer Life Sciences). The results are expressed as TAP
values, which represent the percentage of inhibition of BODIPY
oxidation in human serum with respect to that occurring in a
control sample consisting of BODIPY 581/591 in phosphatidyl-
choline liposomes. For the measurement of serum carotenoids and
tocopherols, analyses were performed using HPLC, as described
by Yeum et al. (20,21). After standard lipid extraction with
chloroform:methanol (2:1) followed by hexane, samples were
analyzed for carotenoids and tocopherols using a reverse phase
HPLC system consisting of a 600S controller (Millipore), Waters
616 pump, Waters 717 autosampler,Waters996 photodiode array
detector, and C30 carotenoid column (3 mm, 150 3 4.6 mm,
YMC). Millenium32 was the operating system. The programma-
ble photodiode array detector was set at 445 and 455 nm for
carotenoids and 292 nm for tocopherols. Carotenoids and
tocopherols were quantified by determining peak areas in the
HPLC chromatograms, calibrated against known standards.
Serum cholesterol and uric acid concentrations for the cohort
were determined according to methods described previously (22).
Other covariates. Information on covariates was obtained at
either the initial home visit or the JHS baseline clinic visit. Age
was computed from self-reported date of birth. Information
regarding presence of self-reported hypertension was assessed
from the medical history questionnaire. Smoking status was
derived from a set of questions regarding cigarette use. Partic-
ipant height and weight were measured by trained technicians at
the clinic visit using physician quality measurement scales in an
exam gown with no shoes. Detailed information regarding the
procedures used forthe anthropometric procedures conducted at
the clinic visit have been published elsewhere (15). BMI was
calculated as weight/height2(kg/m2).
Statistical analyses. Several dietary assessment instruments
were used in the DPASS of the JHS. However, we used data from
the Delta NIRI JHS FFQ (158 item) for this analysis, as this
questionnaire was administered on the day of the blood draw
and is the only dietary questionnaire that was used in the main
JHS cohort. We excluded participants who reported energy
intake outside the plausible range of #600 or $4000 kcal/d9on
the FFQ (n = 34) or whose FFQ had 5 or more food items blank
(n = 2). DPASS participants without blood samples for the TAP
analysis (n = 43) were also excluded, leaving a sample of 420
individuals. For analyses with serum nutrients, due to missing
data, n = 416 for b-carotene and 417 for a-tocopherol. Two
participants had g-tocopherol concentrations below detectable
levels; therefore, the number of observations for those analyses
We examined associations between TAP levels and sample
characteristics. Variables included dietary intakes of antioxi-
dants, fruit and vegetables, and nuts and serum measures of
dietary antioxidants, uric acid, and cholesterol. Servings of
vegetables per day were estimated from questions on the FFQ.
These included vegetable groups such as orange vegetables,
sweet potato, tomato and tomato products, green leafy vegeta-
bles, root vegetables, and other vegetables but did not include
white potato and white potato products. Also, vegetables that
were part of mixed dishes, e.g. mixed dishes with meat were not
91 kcal = 4.184 kJ.
Total antioxidant performance and antioxidant nutrients1965
included. Servings of fruit were also estimated from questions on
the FFQ. These included all citrus and noncitrus fruit and fruit
juice, but not fruit drinks.
Associations of TAP with nuts, including peanuts, peanut
butter, and pecans, were also examined. As mentioned previ-
ously, the FFQ was developed using 24-h recall data from the
Delta region. The serving sizes are therefore reflective of this
As dietary and biological measures of antioxidant nutrients
and foods were skewed, they were log transformed prior to
analysis. Dietary intake data were energy adjusted using the
residual method (23). Log-transformed dietary measurements
were regressed on log-transformed total energy intake to
compute residuals. The predicted value of the dietary measure-
ment for the mean of total energy intake was added back to each
residual, and the antilogarithm of this value was taken. We
tested for interactions between the main dietary and serum
predictors (in continuous form) and sex with respect to TAP
levels. As none were significant, we present the results for men
and women together. We estimated least squares means for TAP
levels by quartile of dietary as well as total (diet + supplement)
intake of a-tocopherol (mg/d), g-tocopherol (diet only, mg/d),
b-carotene (mg/d), vitamin C (mg/d), fruit, vegetables, and nuts
(all servings per day). Because TAP is a new measure of serum
antioxidant status, we examined several variables that were
available for the cohort as potential covariates and confounders
of the association with antioxidants, fruit and vegetables, and
nuts and serum measures of dietary antioxidants and adjusted
for these in the models. After analysis with a simple model, a
second model was further adjusted for age (y), sex, BMI (kg/m2),
energy intake (kJ/d), supplement use (yes/no), current smoking
status (yes/no), and self-reported hypertension (yes/no). Serum
uric acid, which is mainly produced endogenously but is also
affected by dietary intake, was strongly associated with TAP
levels. Serum uric acid was also a significant negative con-
founder between total a- tocopherol intake and TAP. Therefore,
for the analyses with a-tocopherol, we examined the association
between a residual measure of TAP after adjustment for serum
uric acid and a-tocopherol intake.
between TAP and serum b-carotene and a and g-tocopherol
levels. Two models were examined, the first adjusting for age (y),
sex, BMI (kg/m2), serum cholesterol concentrations (mmol/L),
and serum uric acid concentrations (mmol/L) and the second
model further adjusted for current smoking status (yes/no) and
presence of self-reported hypertension (yes/no).
We also present the P-values for test for trend, which were
calculated by assigning subjects the median value of the category
of nutrient or food group or serum antioxidant nutrient being
considered and including this as a continuous variable in the
model. All statistical tests were 2-sided with a significance level
of 0.05. SAS version 9.1 (SAS Institute) was used for all
Age was positively associated with serum TAP levels (P-trend ,
0.01) (Table 1). A higher percentage of women were in the lower
quartile of TAP (75 compared with 45% in the highest quartile;
P, 0.0001). BMI waspositively associated with TAP (P-trend ,
0.05). Although there was a difference in supplement use
across the TAP quartiles (with an increasing trend up to quartile
3), the percentage of supplement users in the highest quartile was
46% compared with 50% in the lowest quartile. Smoking status
did not differ across TAP quartiles. A higher percentage of
participants in the highest quartile of TAP reported hypertension
(66 compared with 48% in the lowest quartile; P , 0.001).
Serum b-carotene, g-tocopherol, and cholesterol concentration
were not associated with TAP. Serum uric acid and a-tocopherol
were associated across TAP levels (P-trend # 0.0001). There
were no associations between intakes of energy, total or dietary
a- or g- tocopherol, and serum TAP levels. Total and dietary b-
carotene intake and vegetable and fruit intake were positively
associated with serum TAP levels. There were weak associations
between dietary and total vitamin C intake and serum TAP level.
Unlike dietary a - and g-tocopherols and vitamin C intakes,
the highest quartile of dietary b-carotene intake with a median
intake of 4.0 mg/d had ~4% higher serum TAP compared with
the lowest quartile of intake, with a median intake of 1.75 mg/d;
tests for trend were also significant (Table 2). The highest
quartile of total b-carotene intake, with a median intake of 4.3
mg/d, was also associated with 3.2% higher serum TAP levels
compared with the lowest quartile with a median intake 1.9 mg/d
and tests for trend were significant. The highest quartile of total
vitamin C intake was also associated with an ~2.5% increase in
TAP levels compared with the lowest.
Serum b-carotene and TAP levels were not associated (Table
3). Individuals in the highest quartile of serum a-tocopherol
concentrations had significantly higher serum TAP compared
with those in the lowest quartile (~5.6% higher). Tests for trend
were also significant. g-Tocopherol concentrations and TAP
levels were inversely associated. No associations were seen for a
further adjusted model.
The highest quartile of vegetable intake, with a median intake
of 1.7 servings/d, was associated with ~4% higher TAP values
compared with the lowest quartile, with a median intake of 0.8
servings/d (Table 4). Although serum TAP did not differ between
quartiles of fruit intake, tests for trend were significant (P ,
0.05). The strongest associations were for combined fruit and
vegetable intake (for both models), with significant associations
between the lowest quartile of intake and the subsequent
quartiles, as well as for trend. Nuts, which are a good source
of vitamin E, were also examined. However, only small amounts
of nuts were consumed in this population and there were no
associations with TAP levels.
Avariety of assays have been developed to measure antioxidant
capacity in plasma. These include the oxygen radical absorbance
capacity assay (ORAC) (24), the Randox Trolox-equivalent
antioxidant capacity assay (25) and the ferric reducing ability of
plasma assay (26). However, most of these assays use either a
hydrophilic or a lipophilic approach, thereby not capturing
valuable information on the interactions that exist between
antioxidants of the 2 compartments (27).
The TAP assay measures the activity of both the hydrophilic
and lipophilic antioxidants in serum/plasma along with their
interactions (14). The results of this study show that, in African
Americans, total a-tocopherol, total vitamin C, total and dietary
b-carotene, fruit, vegetable, and fruit plus vegetable intakes are
associated with serum TAP levels. Serum a-tocopherol was also
associated with this measure of overall antioxidant status.
a-Tocopherol in serum is a potent lipid-soluble antioxidant
(28). In this study, we did not find an association between
increasing quartiles of dietary a-tocopherol intake and TAP
1966Talegawkar et al.
levels, but we did see significantly greater TAP levels in the
highest vs. lowest quartile of total a-tocopherol intake (includ-
ing supplements) and a linear trend across quartiles. This
association remained after adjustment for several covariates.
The median intake of total a-tocopherol intake in the highest
quartile was 285 mg/d, whereas the mean daily dietary intake
of a-tocopherol in this population was ~7 mg/d, which is
considerably lower than the Estimated Average Requirement of
12 mg/d for adults (29). The highest quartile of total
a-tocopherol intake in this population, therefore, represents
supplement use. In accordance with the correlation between
plasma TAP and a-tocopherol in a human plasma model (13)
and in plasma samples from a small number of participants
previously reported by Beretta et al. (14), there was an
association between a-tocopherol and TAP values but only for
those taking supplements.
TAP levels did not differ across g- tocopherol intake
quartiles. The inverse association between serum g- tocopherol
and TAP levels for 1 of the statistical models examined was
surprising. A study that examined the effect of smoking and
environmental tobacco exposure on plasma antioxidant status
in smokers, passive smokers, and nonsmokers found that
whereas several other plasma antioxidant concentrations were
significantly lower in smokers and passive smokers compared
with nonsmokers, the levels of g-tocopherol were elevated even
after adjusting for dietary intakes (30). These results warrant
further investigation into the role of g- tocopherol in oxidative
Both dietary and total b-carotene and total vitamin C intakes
were associated with serum TAP. Intervention studies have
shown that b-carotene and vitamin C supplements alone or in
combinationwith other known antioxidantshave been shown to
improve antioxidant capacity (31) or lower markers of oxidative
stress (32). Although, we did see significantly higher TAP values
with higher b-carotene intake and vitamin C (total intake only)
intakes, results were not reflected in serum b-carotene and TAP
associations. Because serum vitamin C has not been estimated in
the cohort, we were not able to examine its associations with
Sample characteristics of the JHS diet and physical activity substudy participants by
quartiles of TAP1
Current smoker, %
Supplement user, %
Self reported hypertension, %
Serum uric acid,5mmol/L
Total vitamin C,6,7mg/d
Dietary vitamin C,6mg/d
Vegetables + fruit,6,8,9servings/d
59.2 6 0.92
29.6 6 0.66
0.64 6 0.06
27.0 6 1.38
5.78 6 0.41
275 6 7.38
5.18 6 0.10
60.0 6 0.92
29.9 6 0.64
0.73 6 0.06
31.0 6 1.34
5.39 6 0.40
324 6 7.14
4.97 6 0.10
62.4 6 0.92
31.7 6 0.64
0.67 6 0.06
34.4 6 1.33
5.25 6 0.40
361 6 7.15
5.06 6 0.10
62.1 6 0.92
31.4 6 0.64
0.61 6 0.06
32.6 6 1.33
6.39 6 0.40
430 6 7.11
5.29 6 0.10
8198 6 306
55.6 6 11.8
6.98 6 0.21
13.9 6 0.45
2928 6 113
2666 6 106
184 6 19.1
112 6 6.57
1.15 6 0.04
1.39 6 0.09
2.54 6 0.10
0.29 6 0.04
8440 6 296
89.4 6 11.4
6.67 6 0.20
13.3 6 0.44
3115 6 109
2811 6 103
178 6 18.5
109 6 6.36
1.13 6 0.04
1.40 6 0.09
2.53 6 0.10
0.24 6 0.04
8045 6 297
96.0 6 11.4
6.59 6 0.20
13.3 6 0.43
3302 6 109
2937 6 103
220 6 18.5
120 6 6.37
1.12 6 0.04
1.55 6 0.09
2.67 6 0.10
0.23 6 0.04
8168 6 295
64.4 6 11.4
7.27 6 0.20
14.4 6 0.43
3317 6 109
3085 6 102
208 6 18.4
124 6 6.33
1.30 6 0.04
1.61 6 0.09
2.91 6 0.10
0.27 6 0.04
1Values are means 6 SE or %, n = 420, 416 (serum b-carotene), 417 (serum a-tocopherol and uric acid), 418 (serum g-tocopherol) or 419
2Median total antioxidant performance values for Q1 through Q4 were: 64.0, 71.7, 76.5, and 81.2% protection, respectively.
4Continuous variables were examined using linear regression (SAS Proc GLM) with test for trend across median values of total antioxidant
performance in each quartile. Categorical variables were examined with chi-square analysis.
5Adjusted for age and sex and, for serum antioxidant concentrations, also for serum cholesterol. Values for serum antioxidant, cholesterol,
and uric acid concentrations are presented in original scale.
6Adjusted for sex, age, and energy intake (except for energy intake itself). Dietary, total nutrient, and food intakes are presented in original
7Total = dietary + supplement intake.
8Vegetable intakes were calculated from specific questions about vegetable consumption on the FFQ. We were unable to include the
vegetables part of mixed recipes in this calculation.
9Fruit intakes were calculated from specific questions asking about fruit and fruit juice consumption on the FFQ.
10Nut intakes were calculated from specific questions asking about nuts and nut butters on the FFQ.
Total antioxidant performance and antioxidant nutrients 1967
serum TAP levels. Considering that TAP was significantly
(positively) associated with intake of fruit and vegetables and
that this remained after adjustment for dietary intakes of
b-carotene and vitamin C (data not shown), the association of
these food groups with TAP is not solely because of these well-
documented antioxidant vitamins. Intervention studies have
demonstrated increases in overall antioxidant status with
increases in fruit and vegetable intakes (33–35). On the other
hand, single or combinations of antioxidant supplement inter-
ventions have not shown improvements of antioxidant status or
oxidative stress measures (36–38). It is interesting to note that
observational studies have also suggested that higher intake of
foods that are rich sources of these phytochemicals are associ-
ated with lower risk of chronic disease morbidity and mortality
We are not aware of any other study examining associations
between this particular measure of antioxidant status (serum
TAP levels) and dietary intake of antioxidants and antioxidant-
rich foods. The results from our study are consistent with others
that have examined the associations between diet, dietary
estimates of total antioxidant capacity, and other biological
estimates of total antioxidant capacity. In a recent study,
Rautiainen et al. (43) concluded that fruit and vegetables were
major contributors to FFQ-based total antioxidant capacity
measures such as ORAC, total radical-trapping antioxidant
Adjusted mean total antioxidant performance of
JHS DPASS participants by antioxidant
Total a-tocopherol intake, mg/d
Dietary a-tocopherol intake, mg/d
Dietary g-tocopherol intake,2mg/d
Total b-carotene intake, mg/d
Dietary b-carotene intake, mg/d
Total vitamin C intake, mg/d
Dietary vitamin C intake, mg/d
72.2 6 0.53a
72.0 6 0.53a
73.7 6 0.53ab
75.2 6 0.54b
72.0 6 0.73a
72.0 6 0.69a
73.4 6 0.74a,b
74.7 6 0.76b
72.8 6 0.55
73.4 6 0.55
73.5 6 0.55
73.1 6 0.55
72.4 6 0.65
73.1 6 0.65
73.2 6 0.66
72.7 6 0.69
72.7 6 0.74
74.1 6 0.74
72.1 6 0.74
73.8 6 0.74
72.3 6 0.85
74.1 6 0.86
72.6 6 0.87
74.6 6 0.88
72.0 6 0.74a
73.2 6 0.71a,b
74.0 6 0.71a,b
74.5 6 0.71b
72.0 6 0.89a
73.4 6 0.85a
73.8 6 0.87a
74.3 6 0.87a
71.3 6 0.74a
73.5 6 0.74a,b
73.8 6 0.74a,b
74.3 6 0.74b
71.8 6 0.86a
73.7 6 0.86a
73.8 6 0.87a
74.1 6 0.86a
73.1 6 0.74a,b
72.1 6 0.74a
72.8 6 0.74a,b
74.9 6 0.74b
73.3 6 0.83a,b
72.2 6 0.90a
72.6 6 0.89a,b
75.0 6 0.90b
72.7 6 0.74
73.3 6 0.74
73.2 6 0.74
73.7 6 0.74
73.0 6 0.83
73.7 6 0.87
73.1 6 0.87
74.0 6 0.91
1Values are means 6 SE. Within category and column, means with superscripts without
a common letter differ after Tukey’s adjustment for multiple comparisons, P , 0.05.
2TAP values for a-tocopherol (total and dietary) are residuals, adjusted for serum uric acid.
3n = 420 (basic model) and n = 418 (adjusted model).
4Median value of energy adjusted nutrient for quartile.
5Adjusted for age, sex, BMI, energy intake, supplement use, current smoker, and self-
6Test for trend was calculated across median values of intake in each quartile.
Adjusted mean total antioxidant performance of
JHS DPASS participants by serum antioxidant
Serum a-tocopherol, mmol/L
Serum g-tocopherol, mmol/L
Serum b-carotene, mmol/L
71.4 6 0.55a
72.5 6 0.53a,b
73.7 6 0.54b
75.7 6 0.55b
71.6 6 0.61a
72.2 6 0.60a
73.3 6 0.60a,b
75.1 6 0.66b
75.1 6 0.55a
73.0 6 0.54a
72.0 6 0.54a
73.0 6 0.57a
74.2 6 0.66
72.5 6 0.60
72.0 6 0.60
73.1 6 0.63
72.4 6 0.57a
73.5 6 0.55a
72.8 6 0.55a
74.5 6 0.58a
72.4 6 0.60
73.2 6 0.60
72.4 6 0.60
73.8 6 0.66
1Values are mean 6 SE. Within category and column, means with superscripts
without a common letter differ after Tukey’s adjustment for multiple comparisons, P ,
2a-Tocopherol n = 416 (Model 1) and 415 (2); g-tocopherol n = 417 (Model 1) and 416
(2); b-carotene n = 415 (Model 1) and 414 (2).
3Median value of serum antioxidant concentrations are in original scale.
4Adjusted for age, sex, BMI, serum cholesterol, and uric acid.
5Adjusted for above plus current smoker and self reported hypertension.
6Test for trend was calculated across the median value of serum antioxidant
concentration in each quartile.
1968Talegawkar et al.
parameters, and ferric reducing ability of plasma assay. These
dietary estimates were also positively correlated with plasma
measures of ORAC and total radical-trapping antioxidant
parameters. Results from the ATTICA epidemiologic study
(44) demonstrated that, in an apparently healthy population,
plasma total antioxidant capacity was positively associated with
consumption of fruit and vegetables. Our results disagree with a
recent crossover intervention study examining the effects of an
intervention of a high and low total antioxidant capacity diet on
markers of antioxidant status, systemic inflammation, and liver
dysfunction (45). This study did not observe significant differ-
ences in serum total antioxidant capacity measures associated
with the 2 interventions. Unlike our study, where there was a
wide variation in antioxidant and fruit and vegetable intakes,
the intervention study had fewer participants and a similar range
of fruit and vegetable intake due to its study protocol. This may
have prevented them from detecting differences in serum total
antioxidant capacity between the 2 study groups.
In the past there has been criticism leveled against the concept
of “total antioxidant capacity” (46). Most assays use either a
hydrophilic or lipophilic approach and are unable to capture
interactions between fat- and water-soluble antioxidants that
exist or antioxidant enzymes that contribute to the antioxidant
defense systems in the body. Yeum et al. (47) recently demon-
strated that the TAP assay captures the synergistic protective
associations between both water- and fat-soluble antioxidants.
However, it is important to note that, similar to the shortcom-
ings of other assays, TAP cannot capture direct reactive oxygen
or nitrogen scavenging activities.
In the present study, information on nutritional intake was
obtained by FFQ. In the past there have been several criticisms
levied against this method of dietary assessment (48). However,
the FFQ is the method of choice for dietary assessment in large
epidemiological studies for ranking nutritional intakes of
individuals (49). Also, the FFQ used in the present study was
region specific and designed to capture the intake patterns of the
study population and had been previously validated for total
a-tocopherol and b-carotene intakes using corresponding mea-
sures in serum as biomarkers (18,19). Our study participants
were from a population-based cohort and were not disease free.
TAP may be influenced by the presence of disease and hence final
models were adjusted for presence of self-reported hypertension,
because it was one of the most commonly reported heath
conditions. Although we adjusted for a number of covariates, all
observational studies may have residual confounding.
In recent years, several antioxidant supplement trials have
shown lack of benefit and, in some cases, potential harm (50,51).
This has shifted the focus to overall dietary patterns and food
intake rather than single nutrient intakes (52). Although higher
total antioxidant status was associated with antioxidant sup-
plement use, our study also clearly demonstrates that modest
increases in fruit and vegetable intake (1 serving/d of vegetables
or 2 servings/d of fruit and vegetables) were positively associated
with total antioxidant status. Antioxidant nutrients that are
associated with increased fruit and vegetable consumption
include carotenoids and vitamin C (53). Beneficial effects of
increased fruit and vegetable consumption have been attributed
in part to their antioxidant flavonoids. A review of intervention
studies examining the effect of fruit and vegetables on measures
of antioxidant capacity attributed postintervention increases to
a spike in serum/plasma concentrations of uric acid. According
to the authors, fructose intake (mainly due to fruit consumption)
results in purine nucleotide degradation from fructose catabo-
lism, resulting in increased uric acid concentrations and, thereby,
increased antioxidant capacity measures (54).
In general, we found ~4% greater serum TAP levels across
extreme quartile categories of intakes of total a-tocopherol, b-
carotene (total and dietary), total vitamin C, fruit and vegeta-
bles, and serum measures of a-tocopherol. This seemingly small
increase may be due to the fact that endogenous serum
components (e.g. protein, uric acid, etc.) contribute greatly to
overall antioxidant capacity, and dietary micronutrients may,
thus, play a relatively small role. The clinical importance of this
increase in serum TAP levels is not presently known. Further
studies measuring TAP in other populations and examining its
associations with clinical outcomes are warranted.
The author’s responsibilities were as follows: S.A.T., K.J.Y., and
K.L.T. were responsible for the conception and design of the
study and interpretation of the data; S.A.T. performed the
serum antioxidant assessment, statistical analyses, and drafted
the manuscript; K.J.Y., E.J.J., and K.L.T. supervised this work.
K.J.Y. and G.B. performed the serum TAP assessment; K.J.Y., G.
B., and R.M.R. interpreted the serum TAP data; T.C.C. and H.
Adjusted mean total antioxidant performance
of JHS DPASS participants by fruit and
Vegetable intake, servings/d
Fruit intake, servings/d
Vegetable + fruit intake, servings/d
Nut intake, servings/d
72.0 6 0.74a
72.6 6 0.74a
73.2 6 0.74a,b
75.1 6 0.74b
72.5 6 0.84a
72.6 6 0.86a,b
73.4 6 0.88a,b
75.2 6 0.87b
72.1 6 0.74a
73.0 6 0.74a
73.7 6 0.74a
74.1 6 0.74a
72.3 6 0.85a
73.4 6 0.85a
73.6 6 0.89a
74.6 6 0.89a
71.3 6 0.73a
73.1 6 0.73a,b
73.6 6 0.73a,b
75.0 6 0.73b
71.6 6 0.83a
73.5 6 0.85a,b
73.5 6 0.89a,b
75.2 6 0.87b
73.1 6 0.74
73.1 6 0.74
73.3 6 0.74
73.4 6 0.74
72.9 6 0.88
73.1 6 0.89
73.4 6 0.85
73.8 6 0.86
1Values are mean 6 SE. Within category and column, means with superscripts
without a common letter differ after Tukey’s adjustment for multiple comparisons, P ,
2n = 420 (basic model) and n = 418 (multivariate model).
3Median value of energy adjusted food for quartile.
4Adjusted for age, sex, BMI, energy intake, supplement use, current smoker, and self-
5Test for trend was calculated across median values of intake in each quartile.
Total antioxidant performance and antioxidant nutrients 1969
A.T. supervised data collection for the JHS; H.A.T. and K.L.T.
were responsible for funding acquisition. S.A.T. and K.L.T.
were responsible for final content. All authors made critical
comments during the preparation of the manuscript and fully
accept responsibility for the work.
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Total antioxidant performance and antioxidant nutrients1971