Variation in APOE ε4 Prevalence and Brain Health Associations by European Descent in White All of Us Participants
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Importance
The APOE ε4 allele is among the best-established genetic risk factor for Alzheimer’s disease. Different ethnic and racial groups have varying APOE ε4 prevalences. The prevalence of APOE ε4 also varies among European regions, yet White Americans are treated as a monolith, potentially impacting recruitment decisions and risk profile estimations.
Objective
To test whether White Americans of Southern European descent have a lower prevalence of APOE ε4 than their Northern European descent peers, and secondarily, if APOE ε4-brain health outcomes vary by European descent.
Design, setting and participants
Cross-sectional analyses of the nationwide All of Us cohort study in the United States. Overall inclusion criteria were reporting only White race, and countries of descent from Northern, Central or Southern Europe without overlap. Enrollment opened in May 2018. Analyses were conducted April-June 2025.
Exposures
Regions of European descent (Northern, Central and Southern) from the Basics Survey.
Main Outcomes and Measures
APOE ε4 using variants rs429358 and rs7412, coded as zero, one or two copies.
Results
Among those aged ≥18 (n=77,676), the percentage of European descent was 7.7% Southern and 64.7% Northern. Age and female sex at birth were 55.5 years and 55.8% among Americans of Southern and 56.3 years and 57.4% among those of Northern European descent. APOE ε4 allele frequency was 17.4% for one and 0.1% for two copies among Americans of Southern, and 24.9% and 2.0% for Northern European descent. Logistic regression models confirmed these differences: compared to Americans of Southern European descent, those of Northern European descent had an Odds Ratio of having one APOE ε4 allele of 1.60 (1.49-1.71), and 2.21 (1.71-2.88) of having two APOE ε4 alleles. European descent moderated associations between APOE ε4 allele frequency and two brain health outcomes (interaction p≤0.10).
Conclusions and Relevance
The frequency of APOE ε4 among Americans of Southern European descent was lower than that of Northern European descent and associations with some brain health outcomes varied. Future studies need to use probabilistic samples to confirm these findings. The concept of White race might be too broad when making racial comparisons of APOE ε4 frequency and its effects.
Key Points
Question
Is the prevalence of APOE ε4 reduced when comparing Southern European to Northern European descent American adults who identify as only White race?
Findings
In this cross-sectional analysis of a cohort study (n=77,676 American adults), those of Northern European descent had 60% higher odds of having one, and 120% of having two copies of APOE ε4 compared to those of Southern European descent.
Meaning
Among White American adults, the prevalence of APOE ε4 differs by region of European descent; future studies need to confirm these findings using genetically inferred ancestry and probabilistic samples with stronger external validity.
