Obesity and the Metabolic Syndrome

Prospective study of body size and risk for stroke amongst women below age 60

The relation between obesity, particularly abdominal obesity, and risk of stroke amongst women remains unclear. In 1991-1992, a prospective study was initiated in Sweden amongst women who returned a self-administered questionnaire. Through linkage with nation-wide registries, 45,449 women, free of stroke at entry, were followed up until diagnosis of first incident stroke, death, or the end of follow-up in 2002. We estimated multivariate relative risks (RRs) with 95% confidence intervals (CIs) from Cox proportional hazards regression models. A total of 170 incident stroke cases occurred during an average of 11 years of follow-up. The RR of stroke amongst women in the highest compared with the lowest quintile was 2.4 (95% CI 1.3-4.2; P for trend 0.04) for waist-to-hip ratio, 2.5 (95% CI 1.5-4.3; P for trend 0.01) for waist-to-height ratio and 2.3 (95% CI 1.2-4.3; P for trend 0.02) for waist circumference. Adjustment for hypertension and diabetes attenuated these risk estimates. In contrast, birth weight, body mass index (BMI) at age 18, BMI at entry, weight change in adulthood and adult height were not significantly associated with risk of stroke. This study provides evidence that, in contrast to BMI, several different measures of abdominal obesity are strong predictors of stroke in women.

The evolution of severe steatosis after bariatric surgery is related to insulin resistance

BACKGROUND & AIMS

In severely obese patients, factors implicated in the evolution of severe steatosis after bariatric surgery remain unresolved. Our aim was to determine whether insulin resistance (IR) influences the histologic effects induced by bariatric surgery.

METHODS

We prospectively included 185 severely obese patients (body mass index >/=35 kg/m(2)) referred for bariatric surgery. The evolution of IR (IR index = 1/quantitative insulin sensitivity check index) and liver injury with consecutive biopsy was concomitantly assessed before and 1 year after surgery.

RESULTS

At preoperative biopsy, 27% of severely obese patients disclosed severe steatosis (>/=60%). The alanine aminotransferase (P = .01) and IR indexes (P = .04) were independent predictive factors of severe steatosis at baseline. One year after surgery, surgical treatment induced a decrease in body mass index (9.5 kg/m(2); P < .0001), steatosis score (8.5%; P < .0001), and IR index (0.29; P < .0001). The preoperative IR index (P = .01) and preoperative steatosis (P = .006) were independent predictive factors in the persistence of severe steatosis after surgery. Moderate or severe steatosis was more frequently observed in patients who had conserved a higher IR index after surgery than in patients who had improved their IR index (44% vs 20.2%; P = .04).

CONCLUSIONS

IR was independently associated with severe steatosis and predicted its persistence after surgery. The amelioration of IR after surgery is associated with a decrease in the amount of fat. Taken together, the results of this prospective study in severely obese patients demonstrate that severe steatosis and its evolution after surgery are intimately connected with IR.

Asian adolescents have a higher trunk:peripheral fat ratio than Whites

Body fat, especially in the upper body, has been associated with increased risk of chronic disease among adults. Factors associated with these traits among ethnically diverse populations are not well studied. We examined factors influencing body fat and weight among Asian and White adolescent girls from the female adolescent maturation longitudinal study (initial exam plus 2-y follow-up examination) in Hawaii. The objective of this study was to identify and compare influences on and differences in body size and fat distribution among Asian and White adolescent girls. Subjects were identified among age-eligible members of a large HMO. Of the 214 girls recruited for Exam 1, 107 girls returned for Exam 2. The girls' age, ethnicity, a 3-d diet record, and physical activity recall were obtained by questionnaire at both times, and Tanner pubic hair stage and anthropometry were clinically measured by trained staff at both exams. The ethnic proportion of the study sample was 57% Asian and 43% White. Each girl's ethnicity was based on the ethnic proportion of each biologic parent. The percentage of body fat was measured by Lunar Prodigy dual energy X-ray absorptiometry (DXA) at the follow-up exam only. Among various measures of skeletal size and adiposity, only leg length (inversely) and DXA trunk:peripheral fat ratio (directly) were associated with proportion of Asian ethnicity, after adjusting for age, Tanner pubic hair stage, physical activity, and energy intake. In a multivariate analysis focusing on the trunk:peripheral fat ratio, this measure of central obesity was positively associated with proportion of Asian ethnicity (P = 0.001) and bi-iliac breadth (P = 0.002), and negatively associated with birth weight (P = 0.021), after adjustment for Tanner pubic hair stage, physical activity, energy intake, biacromial breadth, and height. In conclusion, Asian adolescents have a higher trunk:peripheral fat ratio than Whites. Adolescent bi-iliac breadth (positively) and birthweight (negatively) are associated with more body fat on the trunk vs. periphery during adolescence.

Regulation of mouse hepatic genes in response to diet induced obesity, insulin resistance and fasting induced weight reduction

Background

Obesity is associated with insulin resistance that can often be improved by caloric restriction and weight reduction. Although many physiological changes accompanying insulin resistance and its treatment have been characterized, the genetic mechanisms linking obesity to insulin resistance are largely unknown. We used DNA microarrys and RT-PCR to investigate significant changes in hepatic gene transcription in insulin resistant, diet-induced obese (DIO)-C57/BL/6J mice and DIO-C57/BL/6J mice fasted for 48 hours, whose weights returned to baseline levels during these conditions.

Results

Transcriptional profiling of hepatic mRNA revealed over 1900 genes that were significantly perturbed between control, DIO, and fasting/weight reduced DIO mice. From this set, our bioinformatics analysis identified 41 genes that rigorously discriminate these groups of mice. These genes are associated with molecular pathways involved in signal transduction, and protein metabolism and secretion. Of particular interest are genes that participate in pathways responsible for modulating insulin sensitivity. DIO altered expression of genes in directions that would be anticipated to antagonize insulin sensitivity, while fasting/ weight reduction partially or completely normalized their levels. Among these discriminatory genes, Sh3kbp1 and RGS3, may have special significance. Sh3kbp1, an endogenous inhibitor of PI-3-kinase, was upregulated by high-fat feeding, but normalized to control levels by fasting/weight reduction. Because insulin signaling occurs partially through PI-3-kinase, increased expression of Sh3kbp1 by DIO mice may contribute to hepatic insulin resistance via inhibition of PI-3-kinase. RGS3, a suppressor of G-protein coupled receptor generation of cAMP, was repressed by high-fat feeding, but partially normalized by fasting/weight reduction. Decreased expression of RGS3 may augment levels of cAMP and thereby contribute to increased, cAMP-induced, hepatic glucose output via phosphoenolpyruvate carboxykinase (PCK1), whose mRNA levels were also elevated.

Conclusion

These findings demonstrate that hepatocytes respond to DIO and weight reduction by controlling gene transcription in a variety of important molecular pathways. Future studies that characterize the physiological significance of the identified genes in modulating energy homeostasis could provide a better understanding of the mechanisms linking DIO with insulin resistance.

Fructose, insulin resistance, and metabolic dyslipidemia

Obesity and type 2 diabetes are occurring at epidemic rates in the United States and many parts of the world. The "obesity epidemic" appears to have emerged largely from changes in our diet and reduced physical activity. An important but not well-appreciated dietary change has been the substantial increase in the amount of dietary fructose consumption from high intake of sucrose and high fructose corn syrup, a common sweetener used in the food industry. A high flux of fructose to the liver, the main organ capable of metabolizing this simple carbohydrate, perturbs glucose metabolism and glucose uptake pathways, and leads to a significantly enhanced rate of de novo lipogenesis and triglyceride (TG) synthesis, driven by the high flux of glycerol and acyl portions of TG molecules from fructose catabolism. These metabolic disturbances appear to underlie the induction of insulin resistance commonly observed with high fructose feeding in both humans and animal models. Fructose-induced insulin resistant states are commonly characterized by a profound metabolic dyslipidemia, which appears to result from hepatic and intestinal overproduction of atherogenic lipoprotein particles. Thus, emerging evidence from recent epidemiological and biochemical studies clearly suggests that the high dietary intake of fructose has rapidly become an important causative factor in the development of the metabolic syndrome. There is an urgent need for increased public awareness of the risks associated with high fructose consumption and greater efforts should be made to curb the supplementation of packaged foods with high fructose additives. The present review will discuss the trends in fructose consumption, the metabolic consequences of increased fructose intake, and the molecular mechanisms leading to fructose-induced lipogenesis, insulin resistance and metabolic dyslipidemia.

Role of exercise training on cardiovascular disease in persons who have type 2 diabetes and hypertension

Exercise training is an essential component in the medical management of patients who have type 2 diabetes and hypertension. Regular exercise improves the cardiovascular health of individuals who have these conditions through multiple mechanisms (Fig. 1). These mechanisms include improvements in endothelial vasodilator function,left ventricular diastolic function, arterial stiffness.systematic inflammation, and reducing left ventricular mass. Exercise training also reduces total and abdominal fat, which mediate improvements in insulin sensitivity and blood pressure, and possibly, endothelial function. Persons who are in a prediabetic stage or those who have the metabolic syndrome may be able to prevent or delay the progression to overt diabetes by adopting a healthier lifestyle, of which increasing habitual levels of physical activity isa vital component. Most persons who have diabetes and hypertension or are at risk for these conditions should be able to initiate an exercise program safely after appropriate medical screen-ing and the establishment of an individualized exercise prescription. Despite the increasing amount of evidence that shows the benefits of exercise training, this modality of prevention and treatment continues to be underused. Although patients' lack of knowledge of the benefits of exercise or lack of motivation contributes to this underuse, a lack of clear and specific guidelines from health care professionals also is an important factor. Clinicians need to educate patients about the benefits of exercise for managing their type 2 diabetes and assist in formulating specific advice for increasing physical activity. Specific instructions should be given to patients, rather than general advice, such as "you should exercise more often." Many cardiac re-habilitation and clinical exercise programs can accommodate patients who have type 2 diabetes and hypertension. Such programs can establish individualized exercise prescriptions and provide an environment that is conducive for "lifestyle change" that underlies long-term compliance to exercise and risk factor modification.

Essential role of protein kinase G and decreased cytoplasmic Ca2+ levels in NO-induced inhibition of rat aortic smooth muscle cell motility

Hyperinsulinemia is a major risk factor for the development of vascular disease. We have reported that insulin increases the motility of vascular smooth muscle cells via a hydrogen peroxide-mediated mechanism and that nitric oxide (NO) attenuates insulin-induced motility via a cGMP-mediated mechanism. Events downstream of cGMP elevation have not yet been investigated. The aim of our study was to test the hypothesis that antimotogenic effects of NO and cGMP in cultured rat aortic smooth muscle cells are mediated via PKG, followed by reduction of cytoplasmic Ca(2+) levels and increased protein tyrosine phosphatase-proline, glutamate, serine, and threonine activity, leading to suppression of agonist-induced elevation of hydrogen peroxide levels and cell motility. Treatment of primary cultures with adenovirus expressing PKG-1alpha mimicked NO-induced inhibition of insulin-elicited hydrogen peroxide elevation and cell motility, whereas treatment with the pharmacological PKG inhibitor Rp-8-bromo-3',5'-cyclic monophosphorothioate (Rp-8-Br-cGMPS) rescued the stimulatory effects of insulin that were suppressed by NO donor. Treatment of cells with insulin failed to increase cytoplasmic Ca(2+) levels, whereas NO donor decreased cytoplasmic Ca(2+) levels in the presence or absence of insulin. Treatment of cells with the Ca(2+) chelator BAPTA mimicked the effects of PKG and the NO donor and increased the activity of PTP-PEST. Finally, treatment with a dominant negative allele of PTP-PEST reversed the inhibitory effect of BAPTA on cell motility and hydrogen peroxide elevation. We conclude that NO-induced inhibition of cell motility occurs via PKG-mediated reduction of basal cytoplasmic Ca(2+) levels, followed by increased PTP-PEST activity, leading to decreased hydrogen peroxide levels and reduced cell motility.

Insulin resistance does not diminish eNOS expression, phosphorylation, or binding to HSP-90

Previously, using an animal model of syndrome X, the obese Zucker rat (OZR), we documented impaired endothelium-dependent vasodilation. The aim of this study was to determine whether reduced expression or altered posttranslational regulation of endothelial nitric oxide synthase (eNOS) underlies the vascular dysfunction in OZR rats. There was no significant difference in the relative abundance of eNOS in hearts, aortas, or skeletal muscle between lean Zucker rats (LZR) and OZR regardless of age. There was no difference in eNOS mRNA levels, as determined by real-time PCR, between LZR and OZR. The inability of insulin resistance to modulate eNOS expression was also documented in two additional in vivo models, the ob/ob mouse and the fructose-fed rat, and in vitro via adenoviral expression of protein tyrosine phosphatase 1B in endothelial cells. We next investigated whether changes in the acute posttranslational regulation of eNOS occurs with insulin resistance. Phosphorylation of eNOS at S632 (human S633) and T494 was not different between LZR and OZR; however, phosphorylation of S1176 was significantly enhanced in OZR. Phosphorylation of S1176 was not different in the ob/ob mouse or in fructose-fed rats. The association of heat shock protein 90 with eNOS, a key regulatory step controlling nitric oxide and aberrant O2−production, was not different between OZR and LZR. Taken together, these results suggest that changes in eNOS expression or posttranslation regulation do not underlie the vascular dysfunction seen with insulin resistance and that other mechanisms, such as altered localization, reduced availability of cofactors, substrates, and the elevated production of O2−, may be responsible.

Lifestyle and dietary modification for prevention of heart failure

This article discusses the factors that contribute most to systolic and diastolic heart failure (HF): ischemic heart disease, hypertension,obesity, diabetes, and nephropathy. Diabetes often follows the insulin resistance syndrome in which obesity and hypertension are combined with dyslipidemia, and obesity is likely causal. Diabetes and hypertension are common causes of nephropathy, which in turn is a common precursor to HF. Insulin resistance, obesity,dyslipidemia, diabetes, and hypertension are risk factors for atherosclerotic coronary disease and left ventricular ischemia. Each is also a risk factor for diastolic dysfunction.

Há aumento do peso corporal nos finais de semana e nas festas de final de ano? Análise em participantes de programa de exercício supervisionado

FUNDAMENTAÇÃO: Acredita-se que o peso corporal (PC) de adultos tende a aumentar fora dos dias úteis, seja pela maior ingestão ou pela redução de exercício. Objetivamos verificar se o PC aumenta nos finais de semana e nas festas de finais de ano. MÉTODOS: Analisamos, retrospectivamente, os dados de 53 adultos (36 homens), com idade entre 38 e 81 anos (64 ± 10), freqüentando um programa de exercício supervisionado - três a seis sessões semanais de 60 minutos, incluindo exercícios aeróbicos, de fortalecimento muscular e de flexibilidade individualmente prescritos. Excluíram-se aqueles que faltaram mais de 25% das sessões, mais de duas semanas consecutivas ou que faziam uso de diuréticos ou outras medicações capazes de afetar o PC. O PC foi registrado antes de cada sessão. Foram analisados os dados registrados em duas semanas do mês de novembro e nas duas sessões pré e pós-festas de final de ano. RESULTADOS: Houve estabilidade no PC - (média ± erro padrão) 74,6 ± 1,7 vs. 74,6 ± 1,7kg -, respectivamente, antes e após o final de semana (p = 0,382), enquanto houve um aumento pequeno, porém significativo, com as festas de final de ano - 74,3 ± 1,7 vs. 74,9 ± 1,7kg - (p < 0,001). Ganhos superiores a 1 e 2% do PC (máximo individual de 3,8%) com as festas de final de ano foram observados, respectivamente, em apenas nove (16,9%) e seis (11,3%) dos indivíduos, com maiores variações absolutas nos indivíduos mais pesados. DISCUSSÃO: Em adultos participantes de um programa de exercício supervisionado, o impacto do final de semana e das festas de final de ano sobre o PC é nenhum ou pequeno e provavelmente restrito a apenas uma parcela pequena dos homens mais pesados. Provavelmente o estilo de vida mais saudável permite com que não haja um desequilíbrio importante entre a ingestão de calorias e o dispêndio de energia pelo exercício físico nas circunstâncias estudadas.

Neurotrophin presence in human coronary atherosclerosis and metabolic syndrome: a role for NGF and BDNF in cardiovascular disease?

The development of atherosclerotic cardiovascular disease is a common comorbidity in patients with the metabolic syndrome, a concurrence of cardiovascular risk factors in one individual. While multiple growth factors and adipokines are identified in atherosclerotic lesions, as well as neurotrophins implicated in both cardiac ischemia and lipid and glucose metabolism, the potential role of neurotrophins in human coronary atherosclerosis and in the metabolic syndrome still remains to be elucidated. Here we describe and discuss our results that represent a novel attempt to study the cardiovascular and metabolic biology of nerve growth factor (NGF), brain-derived neurotrophic factor (BDNF) and mast cells (MC). The local amount of NGF, the immunolocalization of p75 neurotrophin receptor (p75NTR) and the number of MC were correlatively examined in coronary vascular wall and in the surrounding subepicardial adipose tissue, obtained from autopsy cases in humans with advanced coronary atherosclerosis. We also analyzed the plasma levels of NGF, BDNF and leptin and the number of MC in biopsies from abdominal subcutaneous adipose tissue in patients with a severe form of the metabolic syndrome. The results demonstrate that NGF levels are decreased in atherosclerotic coronary vascular tissue but increased in the subepicardial adipose tissue, whereas both tissues express a greater number of MC and a stronger p75NTR immunoreactivity, compared to controls. Metabolic syndrome patients display a significant hyponeurotrophinemia and an increased number of adipose MC; the later correlates with elevated plasma leptin levels. In effect, we provide the first evidence for (i) an altered presence of NGF, p75NTR and MC in both coronary vascular and subepicardial adipose tissue in human coronary atherosclerosis, and (ii) a significant decrease in plasma NGF and BDNF levels and an elevated amount of plasma leptin and adipose MC in metabolic syndrome patients. Together our findings suggest that neuroimmune mediators such as NGF, BDNF, leptin and MC may be involved in the development of cardiovascular disease and related disorders.