kristoff@NET.BIO.NET (Dave Kristofferson) (10/13/89)
Vol. 18, No. 34, September 29, 1989 - Page 9
FULL TEXT OF RFAs FOR ONLINE ACCESS
REQUEST FOR RESEARCH COOPERATIVE AGREEMENT APPLICATIONS
RFA NIH-89-HL-15-P: POSTPRANDIAL LIPOPROTEINS AND
ATHEROSCLEROSIS
P.T. 34; K.W. 0715040, 0765025, 0765032, 0785055
NATIONAL HEART, LUNG AND BLOOD INSTITUTE*
Application receipt date: January 16, 1990
PURPOSE
The Division of Epidemiology and Clinical Applications (DECA)
invites cooperative agreement applications for investigators
to participate, with the assistance of the National Heart,
Lung and Blood Institute (NHLBI), in a multicenter study of
the association of postprandial lipoproteins with
atherosclerosis. This study will evaluate lipoprotein
responses to an oral fat challenge among persons with
evidence of atherosclerosis (cases) and comparable controls.
The assistance mechanism used to support the study is the
cooperative agreement, which is similar to the traditional
NIH research grant. It differs from a research grant in the
extent and nature of NHLBI staff involvement. Applications
received in response to this request will participate in a
single competition.
DISCIPLINES AND EXPERTISE
This RFA seeks multidisciplinary research, requiring
cooperation of persons with biochemical and epidemiological
expertise, and access to both an expert laboratory and a
screened or examined population from which representative
cases and comparable controls are drawn. Lipid measurements are
needed, but currently available methods for such
measurements are complex. Expertise
for evaluating subjects for evidence of atherosclerotic
disease also is needed.
BACKGROUND
General
Fatty diets are a likely cause of atherosclerosis, and
lipoproteins appearing in blood after a fatty meal may be
particularly atherogenic. Yet nearly all published research
on the relationship of blood lipids to atherosclerosis in
humans has measured lipids only in fasting or casual
samples. This initiative tests the hypothesized
atherogenicity of postprandial lipoproteins. It originated
in the Division of Epidemiology and Clinical Applications
with input from the Division of Heart and Vascular Diseases
and the two Divisions' Advisory Groups and was approved in
May 1989 by the National Heart, Lung, and Blood Advisory
Council.
Scientific Background
The atherogenicity of postprandial lipoproteins, particularly
remnants of triglyceride-rich particles, is suggested by in
vitro studies of "foam cell" induction, feeding experiments
in animals, and observations on type III hyperlipoproteinemia
in humans. Indirect evidence for the hypothesis arises from
research on conditions characterized by high fasting
triglycerides and low HDL-cholesterol (e.g., diabetes,
obesity, some familial hypertriglyceridemias), persons with
denser LDL particles or elevated apolipoprotein B levels, and
studies associating atherosclerosis with elevated levels of
intermediate-density lipoproteins.
The hypothesis received direct support from Krauss (1987),
who reported that chylomicron remnant concentrations
identified using a retinyl-palmitate marker were nearly twice
as high ten hours post-load in twenty coronary patients as in
controls. Similar results were seen from a study
identifying chylomicron remnants four hours post-load by
apoprotein B-48 measurement (Simons 1987), but discrimination
between cases and controls was weaker with this method.
Neither study had the statistical power to evaluate the
relative associations of fasting and postprandial
measurements with disease.
The postprandial state differs markedly from the fasting
state in persons consuming Western diets. Blood triglyceride
concentrations may double a few hours after a fatty meal and
remain elevated for ten hours, or longer if another fatty
meal is consumed. Chylomicron remnants are still found in
plasma after triglycerides return to baseline levels
(Weintraub 1987). Responses to a fatty meal vary
considerably among persons but in standardized tests tend to
be consistent over time within persons.
Since the transient, postprandial state is subject to
alteration by many factors, the postprandial hypothesis is
difficult to test in persons with clinically apparent
disease, such as acute coronary heart disease. Lipid
metabolism is altered in the recovery period and as a result
of drugs and diets prescribed for treatment (Krone 1988,
Schaefer 1987, Rohlfing 1986). Lipid-lowering drugs, beta
blocking agents, diuretics, hormones, and other medications
known to alter lipid metabolism might affect postprandial
more than fasting lipids (Shulman 1983).
Thus, untreated, asymptomatic populations screened for early
evidence of subclinical atherosclerosis are advantageous
sources for study cases and controls. Examples might include
persons with and without lesions demonstrated by ultrasound
examination of carotid or other arteries (Salonen 1988), or
persons with unexpected electrocardiographic evidence of
silent ischemia or infarction. Persons with symptomatic
atherosclerotic diseases may be appropriate cases for this
study if not using prescribed diets or lipid-altering
medications.
Results of this research are intended to apply to
atherosclerosis typically found in general populations.
Explanations are sought for the occurrence of atherosclerotic
disease in persons without elevated fasting lipids. Thus,
the question is best examined if participants are
representative, with a broad range of lipid levels, not
limited to primary hyperlipidemias or hyperlipidemias
secondary to specific medical conditions.
Use of non-comparable controls often obscured results in
previous studies; none selected cases and controls by
screening test from the same general population. Moreover,
where the cases were patients, self-selected to a hospital or
clinic, the special effort needed to find comparable
controls, such as neighborhood matching, was seldom
undertaken. Furthermore, these studies did not optimize
case-control discrimination by thoroughly evaluating controls
for absence of atherosclerotic disease.
Case-control comparability can be impaired if subjects
perceive a study as inconvenient or uncomfortable; volunteer
bias is created if participation is lower among healthy
controls than cases. Thus, while confinement to a metabolic
ward and frequent blood monitoring might enhance
standardization, such methods may be inappropriate in this
study. Pre-test dietary standardization may have another
disadvantage: if it alters postprandial metabolism, it could
bias the association observed between atherosclerosis and the
usual postprandial response participants experience in their
free-living state.
GOAL OF THE ACTIVITY
The objective of the research supported by this Request for
Applications (RFA) is to
determine whether postprandial lipoproteins are associated
with atherosclerosis, and, if so, whether the association is
statistically independent of that between fasting
lipoproteins and atherosclerosis.
In order to test the hypothesis, it is expected that
lipoproteins will be measured in cases (persons with
atherosclerosis) and comparable controls (persons with
evidence of minimal or no atherosclerosis), both before and
after a fatty meal challenge.
OVERVIEW
Applicants may each select different types of atherosclerotic
cases for study (e.g., carotid or coronary disease). If so,
the hypothesis should be tested separately for each type;
data from diverse types of case should not be pooled for
analysis. However, it is important that results be
comparable from center to center, and that each center
provides a test of the same hypothesis. To assure that
applicants have a common understanding of the collaboration
needed, several features of this study are provided here.
Firstly, cases should be well-defined, representative and not
treated with lipid-altering drugs; controls should be fully
comparable
to the cases in each center. Secondly, sample sizes must be
adequate. Finally, investigators ultimately must reach
agreement on a limited set of elements of a common core
protocol (though other study elements may vary). Possible
core protocol elements are discussed here for illustrative
purposes only.
The nature of the studies to be carried out is in the hands
of the investigators. The collaborative protocol will be
developed by the Project Steering Committee, composed of
awardees and the NHLBI Project Scientist. The study will
move into its operational phase only with the concurrence of
both the awardees and the Institute.
SCOPE OF ACTIVITY
This RFA will support one to four groups, as required to
obtain the needed sample size.
The study hypothesis requires a sample size adequate to
detect the association of postprandial lipoproteins with
atherosclerosis after adjusting for effects of fasting
lipids. Such adjustment is important because fasting lipids
(particularly triglycerides and high-density lipoproteins)
are strongly associated with postprandial lipoproteins and
atherosclerosis. Sample size estimates in the table below
pertain to estimates of chylomicron remnant levels 10 hours
post load and the data cited. Investigators may make other
assumptions to justify alternative sample sizes.
The table shows 300 cases and 300 controls needed to detect a
26% case-control difference in remnant concentrations; 200
cases and controls for a 32% difference. Since cases-control
differences may not exceed 25 to 30 percent after adjusting
for fasting lipids, this test appears to require sample sizes
of such magnitude.
Sample Sizes for Detecting Case-Control Differences
N cases 300 200 100 75 50 30
Difference 26% 32% 45% 52% 63% 82%
Assumptions: 5% level of significance, 80% power; means and
variance from Krauss (1987) for chylomicron remnant levels 10
hr post-load; number of controls = number of cases.
To avoid the need for pooling data across case types, such a
sample size would be needed for a single case type (e.g.,
carotid disease, or coronary disease). These numbers might
be obtained from a single center, or several centers
selecting the same case type.
It would be useful to determine if postprandial lipoproteins
are significantly elevated for several case types. This
could be addressed by univariate analysis, not adjusted for
fasting lipids, and a smaller sample size. Fifty cases of
one type with its controls should detect a 63% case-control
difference (see table), a difference which may reasonably be
expected in unadjusted analyses (Krauss 1987). However,
testing independent effects of postprandial lipoproteins is
the priority of the RFA. The larger sample size needed
means that this test can probably be undertaken for only one
case type.
This RFA cannot support general population screening. The
applicant is assumed to have a source of cases, either a
population already screened for evidence of atherosclerosis
or a population-based group of patients. However, resources
will be available for uniform testing, re-evaluating all
potential cases and controls to assure eligibility criteria
are met.
Participant evaluation may also include measuring major
atherosclerosis risk factors and factors which influence
postprandial lipemia. Recording participants' usual diets
might permit assessment of their effects on postprandial
lipoproteins. Though participants will not be taking known
lipid-altering medications, a current medication history
would permit discovery of unsuspected drug-lipid effects.
Participants should be old enough to have detectable
atherosclerosis and young enough for lipids to influence the
disease. Comparability may be enhanced if all participants
are within 35-70 years of age. Both sexes are of interest,
since their postprandial responses appear to differ
substantially. Inclusion of women and minority populations
is encouraged; and if they are excluded, reasons for their
exclusion must be provided in the application. Minority
institutions are encouraged to apply, and other institutions
are encouraged to establish collaborative arrangements with
minority institutions.
Applicants should describe the source population for their
cases and controls, the definitions of cases and controls to
be used, the availability of participants meeting inclusion
and exclusion criteria, their approach to participant
selection and evaluation, and
a rationale and justification for these methods.
Applicants should provide a rationale for the fat challenge
test proposed and describe their methodology and laboratory
capability in detail. The fat challenge test should be
acceptable to the target population, so that volunteer bias
is avoided. Blood sampling may be timed to measure late
postprandial remnant elevations and estimate peak or near-
peak lipemia. Fasting measurements may include factors known
to influence postprandial lipoproteins. Post-challenge
measurements should include lipoprotein components
hypothesized to be atherogenic and may include non-
lipoprotein factors which are responsive to lipemia and may
contribute to atherogenesis (e.g., hemostatic factors).
Applicants must be prepared to accept elements of a core
protocol common to all centers to assure the needed
comparability. Non-core study elements may differ across
centers, permitting centers to make unique scientific
contributions. The core protocol will be developed by the
successful investigators after award of the cooperative
agreements (see Governance below). Items which may be part
of the core protocol include certain baseline and post-
challenge lipoprotein measurements, meal composition, timing
of some of the blood samples, and recording of risk factors.
Investigators might recommend certain standard data
collection forms (e.g., dietary questionnaire) and central
training in their use. They may also decide to coordinate
elements of their laboratory quality control. Core post-
challenge measurements might include only those the study
hypothesis requires, for example, chylomicron remnants. Non-
core elements may include a variety of measurements related
to postprandial lipemia or its effects.
Awards will be funded for three years. Investigators should
budget for meetings in Bethesda, MD for planning and to
compare progress and results (see expected schedule of
meetings in section, Study Phases).
STUDY PHASES
The study may be divided into three phases: planning;
recruitment evaluation and testing; and data analysis.
Budgets should be provided for each phase separately.
Phase I
The goal of Phase I will be study design. This phase may
take approximately three months. Meetings of the Steering
Committee composed of Principal Investigators and the NHLBI
Project Scientist will be held approximately three times
during this phase. The primary task of the Steering
Committee in this phase is the core protocol: the study
elements which all centers must standardize and share in
order to assure that each tests the same hypothesis. The
study will move into its operational phase only after NHLBI
approval of this protocol.
Phase II
In Phase II, study participants are recruited, evaluated and
tested. It is anticipated that this phase may take
approximately two years and three months. Centers implement
the common protocol developed in Phase I. The Steering
Committee will meet approximately three times during this
phase. There may be additional communication by telephone
conference calls.
Phase III
Phase III will include close-out activities, data analyses
and manuscript preparation. It is expected that this phase
would last approximately 6 months. Each center is responsible
for its own data analysis and most of the manuscript
preparation. However, it is anticipated that at least one
collaborative publication will examine postprandial case-
control differences in some of the core measurements, in
parallel analyses comparing results for each major case type.
At least one meeting of the Steering Committee as well as
periodic conference calls may be necessary during this
period.
STUDY RESPONSIBILITIES, GOVERNANCE and FUNDING
The primary governing body of the study will be the Steering
Committee, composed of principal investigators of the study
centers and the NHLBI Project Scientist. Subcommittees may
be formed on such topics as quality control, and will also
have NHLBI representation. Unless otherwise explicitly
provided, non-NHLBI investigators will have the lead role in
the Steering Committee and its subcommittees. The first
meeting of the Steering Committee will be convened by the
NHLBI Project Scientist. All major scientific decisions will
be determined by vote of the Steering Committee. The
Committee will have primary responsibility for the
development of the study protocol, facilitating conduct of
the study, and reporting study results.
TERMS AND CONDITIONS OF AWARD
It is anticipated that one to four awards will be made under
this RFA for a total of approximately 2.7 million dollars
(including direct and indirect costs) over a three-year
period. Funding is expected to begin on or about July 1,
1990. Applications from foreign institutions will be
considered only if the applicant provides detailed evidence
of special relevant opportunities not available in a U.S.
population.
The administrative and funding mechanism to be used to
undertake this program will be the cooperative agreement, an
assistance mechanism.
Under the cooperative agreement, the NIH assists, supports
and/or stimulates and is involved substantially with
recipients in conducting a study by facilitating performance
of the effort in a "partner" role. Consistent with this
concept, the tasks and activities in carrying out the studies
will be shared among the awardees and the Institute project
scientist. The tasks or activities in which awardees will
have substantial responsibilities include protocol
development, participant recruitment and follow-up, data
collection, quality control, interim data and safety
monitoring, final data analysis and interpretation,
preparation of publications, collaboration with other
awardees and the NHLBI project scientist. The NHLBI project
scientist will have substantial responsibilities in protocol
development, quality control, interim data monitoring, final
data analysis and interpretation, preparation of
publications, collaboration with awardees, coordination and
performance monitoring. It is anticipated that awardees will
have lead responsibilities in protocol development, final
data analysis and interpretation, and in the preparation of
most publications. The NHLBI project scientist will have
lead role responsibilities in quality control and in
preparation of some publications and will serve as a member
of the Steering Committee and its subcommittees.
Any disagreement that may arise in scientific matters between
award recipients and NHLBI may be brought to arbitration. An
arbitration panel will be composed of three members - one
selected by the Steering Committee (with NHLBI member not
voting) or by the individual awardee in the event of an
individual disagreement, a second member selected by NHLBI
and the third member selected by the two prior members. This
special arbitration procedure in no way affects the awardee's
right to appeal an adverse action that is otherwise
appealable in accordance with the PHS regulations at 42 CFR
part 50, subpart D and HHS regulation at 45 CFR part 16.
These special Terms of award are in addition to and not in
lieu of otherwise applicable OMB administrative guidelines,
HHS Grant Administration Regulations at 45 CFR part 74, and
other HHS, PHS and NIH grant administration policy
statements.
The National Heart, Lung, and Blood Institute Advisory
Council reviewed and approved the concept for this Request
for Applications in May 1989.
The Institute reserves the right to terminate or curtail the
study (or an individual award) in the event of (a)
substantial shortfall in participant recruitment, data
reporting, quality control or other major breech of the
protocol; or (b) substantive deviations from the RFA
objectives or agreed-upon protocol; or (c) human subject
ethical issues that may dictate a premature termination.
REVIEW PROCEDURES AND CRITERIA
General Considerations
All applicants will be judged on the basis of the scientific
merit of their proposed study and their documented ability to
conduct the essential study components as outlined in the
Scope of Activity and Overview sections of this Request for
Applications.
Review Method
Upon receipt, applications will be reviewed for
responsiveness to the objectives of this RFA. If an
application is judged unresponsive at this stage, it will be
returned to the applicant. All applications responsive to
this RFA will be reviewed initially for scientific and
technical merit by a special review group, comprised of
experts in lipids, atherosclerosis and population studies,
convened for this purpose by the Division of Extramural
Affairs, NHLBI. Subsequently, they will be reviewed by the
National Heart, Lung, and Blood Advisory Council, most likely
at its May 1990 meeting.
Following primary scientific merit review, some applicants
may receive further inquiry from Institute program staff.
This may focus upon scientific or technical questions arising
from the peer review or upon primarily operational and
administrative questions. The inquiry may involve no more
than a telephone call or letters, or it may take the form of
a site visit or reverse site visit.
In addition to the review criteria listed below, Institute
review will consider the adequacy for testing the study
hypothesis of the number of study subjects provided by the
combination of acceptable applications.
If an application submitted in response to this RFA is
substantially similar to a research grant or cooperative
agreement application already submitted to the NIH for
review, the applicant will be asked to withdraw either the
pending application or the new one. Simultaneous submission
of identical applications is not allowed.
Review Criteria
Applicants are encouraged to submit and describe their own
ideas on how best to meet the goals of the study.
Applications will be judged primarily on their overall
scientific quality and the following review criteria:
1. Availability of, and plan for selecting study
participants:
o well-defined, representative atherosclerotic cases, not
treated with lipid-altering drugs or diet;
o representative, healthy controls, selected from the same
population as, and fully comparable to, the cases; and
o adequate numbers; at a minimum, enough to estimate case-
control differences in univariate analysis. As stated
above, an application may be given preference if it provides
the larger numbers needed for analyses adjusting for fasting
lipids, or if it does so in combination with other
applications selecting the same case-type.
2. Participant evaluation. Plan and demonstrated ability to
assess:
o cases and controls in a uniform manner for presence or
absence of atherosclerosis, and
o major factors believed to be associated with
atherosclerosis or postprandial lipemia.
3. Fat challenge test:
o justification for composition of test meal selected,
o choice of potentially atherogenic lipoprotein (or related)
factors for measurement,
o plan and demonstrated ability to measure them accurately,
and
o feasibility of overall test and appropriateness for
population tested.
4. Qualifications and experience of key staff for both the
laboratory and population activities required for this
research. Adequacy of facilities, resources and staffing.
5. Appropriateness of budget for work proposed.
Each applicant should submit an adequately justified budget
for each phase of the study for a total of three years of
support. Estimates of staffing needs, including the
Principal Investigator and other professional and support
staff, must be included.
METHOD OF APPLYING
Letter of Intent
Prospective applicants are asked to submit a letter of
intent. This should be brief but name the Principal and Co-
Investigators and identify cooperating institutions and
populations to be studied. The Institute requests such
letters only for the purpose of providing an indication of
the number and scope of applications to be received and
usually does not acknowledge their receipt. A letter of
intent is not binding, and it will not enter into the review
of any application subsequently submitted, nor is it a
necessary requirement for applications. This letter of
intent, which should be received no later than December 15,
1989, should be sent to:
C. James Scheirer, Ph.D.
Review Branch, DEA, NHLBI
Westwood Building, Rm 548
5333 Westbard Avenue
Bethesda, MD 20892
Format for Applications
Submit applications on PHS form 398 (revised 10/88), the
application form for the traditional research project grant.
This form is available in an applicant institution's office
of sponsored research or business office, or from the Office
of Grants Inquiries, National Institutes of Health, 5333
Westbard Ave. Rm 449, Bethesda MD 20892. Use the
conventional format for research project grant applications
and ensure that the points identified in the section on
"Review Procedures and Criteria" are fulfilled.
The format and instructions for budget estimates provided
should be followed. Indirect costs will be awarded in the
same manner as for research grants. Budgets will be reviewed
on the basis of appropriateness for the work proposed.
Allowable costs and policies governing the research grant
programs of the NIH will prevail. Overlapping support or
duplication of funding will not be allowed, and a summary of
all actual and pending sources of support for each key
investigator participating in the study should be included.
These summaries of other funding should identify by name the
Principal Investigator of each award and should include the
source of the funds with identifying grant or other award
number, percent effort committed, the amount of the award
for the current year, the total amount of the award, the
project period for which the award was made.
This RFA is a one-time request for applications. To identify
the application as a response to this RFA, check "yes" on
Item 2 of page 1 of the application and enter the title,
Postprandial Lipoproteins and Atherosclerosis: RFA
NIH-89-HL-15-P.
THE RFA LABEL INCLUDED IN THE 10/88 REVISION OF PHS FORM 398
MUST BE AFFIXED TO THE BOTTOM OF THE FACE PAGE OF THE
ORIGINAL COMPLETED APPLICATION FORM. FAILURE TO USE THIS
LABEL COULD RESULT IN DELAYED PROCESSING AND REVIEW OF YOUR
APPLICATION.
If an applicant proposes studying more than one major case-
type (e.g., carotid and coronary disease), their budgets
should be separate.
Application Procedure
Send or deliver the completed application and four (4)
signed, exact photocopies of it to:
Division of Research Grants
Westwood Building, Room 240
National Institutes of Health
Bethesda, MD 20892**
Send two (2) additional copies of the application to:
C. James Scheirer, Ph.D.
Review Branch, DEA, NHLBI
Westwood Building, Rm 548
5333 Westbard Avenue
Bethesda, MD 20892
Telephone 301-496-8818
IT IS IMPORTANT TO SEND THESE TWO COPIES AT THE SAME TIME AS
THE ORIGINAL AND FOUR COPIES ARE SENT TO THE DIVISION OF
RESEARCH GRANTS. OTHERWISE, THE NHLBI CANNOT GUARANTEE THAT
THE APPLICATION WILL BE REVIEWED IN COMPETITION FOR THIS RFA.
Application must be received by January 16, 1990. An
application not received by this date will be considered
ineligible.
Timetable
Letter of Intent December 15, 1989
Application Receipt Date January 16, 1990
Review by National Heart, Lung, and
Blood Advisory Council May 24-25, 1990
Anticipated Award Date July 1, 1990
Inquiries
Inquiries regarding this announcement may be directed to the
Project Scientist:
A. Richey Sharrett, M.D., Dr.P.H.
SEEB, DECA, NHLBI
Federal Building, Rm 2C08
7750 Wisconsin Avenue
Bethesda, MD 20892
Telephone 301-496-8887
REFERENCES
Krauss XH, Groot P, van Ramshorst E, et al. Chylomicron
Metabolism in Coronary Atherosclerosis. Arteriosclerosis
1987;7:531a
Krone W and Nagele H. Effects of antihypertensives on plasma
lipids and lipoprotein metabolism. Amer Heart J
1988;116:1729-34
Rohlfing JJ and Brunzell JD. The effects of diuretics and
adrenergic-blocking agents on plasma lipids. West J Med
1986;145:210
Salonen R, Seppanen K, Rauramaa R, et al. Prevalence of
carotid atherosclerosis and serum cholesterol levels in
Eastern Finland. Arteriosclerosis 1988;8:788-92
Schaefer EJ, McNamara JR, Genest J, Wilson PWF, Albers JJ and
Ordovas JM. LDL particle size, lipoproteins, and apoproteins
in premature coronary artery disease: confounding effects of
beta blockers. Circulation 1987;76:IV 531
Shulman RS, Herbert PN, Capone RJ et al. Effects of
propranolol on blood lipids and lipoproteins in myocardial
infarction. Circulation 1983;67 (suppl I):I-19
Simons LA, Dwyer T, Bernstein L et al. Chylomicrons and
chylomicron remnants in coronary artery disease: a case-
control study. Atherosclerosis 1987;65:181-9
Weintraub MS, Eisenberg S, Breslow JL. Different patterns of
postprandial lipoprotein metabolism in normal, type IIa, type
III, and type IV hyperlipoproteinemic individuals. J Clin
Invest 1987;79:1110-19
* The programs of the Division of Epidemiology and Clinical
Applications, National Heart, Lung, and Blood Institute, are
identified in the Catalog of Federal Domestic Assistance,
Numbers 13.837-13.839. Awards will be made under the
authority of the Public Health Service Act, Section 301 (42
U.S. 241) and administered under PHS grant policies and
Federal regulations, most specifically 42 CFR Part 52 and 45
CFR Part 74. This program is not subject to the
intergovernmental review requirements of Executive Order
12372, or to Health Systems Agency review.