The link between obesity, chronic inflammation and insulin resistance

Introduction The prevalence of obesity is increasing rapidly in the developed world, where it constitutes a major public health challenge. Obesity, particularly visceral obesity, is associated with a chronic inflammatory response, characterized by abnormal adipokine production, and the activation of some pro-inflammatory signalling pathways, resulting in the induction of several inflammatory biomarkers shown to have causal relationships with morbidities such as insulin resistance, type 2 diabetes mellitus and cardiovascular disease. The role of insulin Insulin has various tissue specific roles. The principle mechanism by which insulin regulates blood glucose is through binding of insulin to the insulin receptor leading to downstream tyrosine phosphorylation of protein substrates that then engage and activate PI3K. This leads to downstream signalling through Protein Kinase B and Insulin receptor substrate-1, which results in GLUT4 translocation from its intracellular pool to the plasma membrane and glucose transport into the cell (Taniguchi et al., 2006, Thirone et al., 2006). In adipose tissue, insulin is antilipolytic, whereby it inhibits the release of fatty acids from adipocytes by decreasing the activity of hormone-sensitive lipase and adipose triglyceride lipase (Duncan et al., 2007). In the liver, insulin decreases the release of glucose from the liver by inhibiting hepatic glycogenolysis and the expression of key gluconeogenic enzymes (Nakatani et al., 2007). In skeletal muscle, insulin promotes glucose uptake by stimulating translocation of the GLUT4 glucose transporter to the plasma membrane, and impaired skeletal muscle insulin signalling results in decreased glucose disposal (Gual et al., 2005). Obesity, insulin resistance and chronic inflammation Insulin resistance is a complex metabolic disorder resulting from aetiologies dependent on the pathophysiologic state. Obesity is a major cause of insulin resistance and the prevailing hypothesis is that chronic, low-grade inflammation associated with obesity is an important aetiological mechanism in decreasing insulin signalling (Xu et al., 2003). In this regard, inflammation causes cell autonomous insulin resistance in muscle, liver and adipose cells and activated tissue macrophages can underlie tissue-autonomous inflammatory processes. Overnutrition increases the rate of fatty acid delivery to skeletal muscle and the liver, exceeding the rates of intracellular fat oxidation and triglyceride synthesis and storage. Consequently, insulin secretion rises as a metabolic adaptation for the decreased capacity to handle glucose resulting in

hyperinsulinaemia and insulin resistance (Moller et al., 1991).The ratio of visceral to subcutaneous fat is a proxy measure of insulin resistance. Overweight and obesity are commonly defined on the basis of body mass index (BMI), however, BMI fails to consider body fat distribution which has been shown to be a significant predictor of several diseases (Grundy et al., 2002). The rate of lipolysis is higher in visceral adipose tissue than subcutaneous adipose tissue, leading to increased circulation of NEFA. Therefore, the risk of developing insulin resistance and hyperinsulinaemia increases with increasing visceral adipose tissue accumulation (Wajchenberg et al., 2000). Adipose tissue hypertrophy and hyperplasia in obesity leads to clusters of adipocytes remote to the vascular supply in expanding tissue. This causes hypoxic loci and adipocyte cell death within the adipose tissue necessitating clearance of dead adipocytes and vascularisation of the tissue (Surmi et al., 2008).Importantly, it has been suggested that macrophages may act to stimulate angiogenesis and clear necrotic tissue in the adipose tissue, which could be a rationale for why macrophages infiltrate adipose tissue (Pang et al., 2008). Furthermore, immune cells such as neutrophils and CD8+T-cells infiltrate the adipose tissue and contribute to macrophage recruitment via the release of inflammatory cytokines and chemokines (Nishimura et al., 2009). In obesity, there is a shift from the M2 macrophages to pro-inflammatory M1 macrophages, induced by interferon- (IFN-) and lipopolysaccharide (LPS), which release cytokines that activate pro-inflammatory intracellular signalling pathways such as JNK and IKK, both in a paracrine manner and in distal endocrine tissues. M1 macrophages may also generate reactive oxygen species such as NO via activation of inducible NO synthase (Mantovani et al., 2004). Moreover, the dynamic restructuring of adipose tissue in obesity induces low-grade inflammation in response to microhypoxia, which alters levels of several circulating factors such as an increase in the plasma levels of tumour necrosis factor- (TNF-), interleukin-6 (IL-6), and other biological markers of inflammation such as C-reactive protein (CRP) (Bastard et al., 2002,Hotamisligil et al., 1993, Ford et al., 2003) .

Figure 1. Olefsky J and Glass CK. Macrophages, Inflammation, and Insulin Resistance. Annu. Rev. Physiol. 2010. 72:219 46.

TNF-, produced mainly by macrophages and lymphocytes, has been shown to play a major role in the pathophysiology of insulin resistance through the phosphorylation of the insulin receptor substrate-1 (IRS-1) protein on serine residues, thereby preventing its interaction with the insulin receptor beta subunit, and disrupting the insulin signalling pathway (Nguyen et al., 2005). IL-6, like TNF-, exerts long-term inhibitory effects on the gene transcription of IRS-1, GLUT-4 and PPAR in adipocytes. This effect of IL-6 is accompanied by a marked reduction in IRS-1 protein expression and reduction in insulin-stimulated IRS-1 tyrosine phosphorylation coinciding with impaired insulin-stimulated glucose transport (Rotter et al., 2003). Several other pro-inflammatory mediators have also been found to be over-expressed in the insulinresistant state such as leptin, monocyte chemotacticprotein (MCP)-1 and resistin (Trayhurn et al.,

2004, Steppanet al., 2001). Leptin which increases in proportion to fat mass promotes cholesterol ester synthesis in macrophages in a hyperglycaemic environment, an important process in the formation of foam cells in atherosclerosis (Guagnano et al., 2003). Whereas the secretion of proinflammatory cytokines is enhanced, the production of insulin-sensitizing adipokines is reduced, such as adiponectin that would normally decrease hepatic gluconeogenesis and increase lipid oxidation in muscle (Yang et al., 2001). An alternative hypothesis Though inflammation associated with adipokines has become the prevailing hypothesis, it cannot entirely explain the mechanisms for development of insulin resistance. The lipid overload hypothesis states that enlarged adipocytes leak fatty acids which activates diacylglycerol (DAG) and causes accumulation of DAG in the muscle. The four main causes of net DAG accumulation are excess caloric intake, defects in adipocyte metabolism (which would include lipid storage and lipolysis), defects in mitochondrial fatty acid oxidation and gene variation in apolipoprotein C3, leading to inhibition of lipoprotein lipase activity. Increased intracellular diacyglycerols lead to activation of PKC- and PKC- in skeletal muscle and liver, respectively, which, in turn, decreases insulinstimulated IRS-1/IRS-2 tyrosine phosphorylation, PI3K activation and downstream insulin signalling. In the muscle, this results in decreased muscle glycogen synthesis, owing to reduced insulinstimulated GLUT4 translocation to the plasma membrane (Kumashiro et al., 2011). In the liver, this results in decreased hepatic glycogen synthesis, owing to decreased activation of glycogensynthase, and increased hepatic gluconeogenesis.

Figure 2. Taubes G. Prosperitys plague. Science 2009 (325)P256-260.

Nutritional interventions The most dramatic improvements in the clinical manifestations of insulin resistance are attained through weight loss (Kim et al., 2004). However, low fat/high CHO diets, of the same calorie content, do not improve insulin sensitivity. These benefits are only gained through a reduction in caloric intake. In fact, the high CHO content of the aforementioned diet accentuates insulin resistance as the more insulin resistant an individual, the greater is the amount of insulin that must be secreted in response to a CHO-enriched diet in order to maintain glucose homeostasis. In addition, this dietary approach has consistently been shown to stimulate hepatic VLDL-TG synthesis and secretion, leading to an increase in concentration of TG-rich lipoproteins. A hypoenergetic diet decreasing caloric intake by 500-700 calories per day is recommended to improve insulin sensitivity (Ferroni et al., 2004). To a lesser extent, modifications in both macro and micronutrients in the diet have many antiinflammatory effects. Long-chain (LC) n-3 PUFA regulate gene expression through transcription factors such as PPAR and NF-kB and via eicosanoid production, reducing pro-inflammatory cytokine production from many different cells including the macrophage thereby, modulating the intensity and duration of inflammatory responses (Sijben et al., 2007). LC n-3 PUFA may therefore offer a

useful anti-inflammatory strategy to decrease obesity-induced insulin resistance. LC n-3 PUFA are found in fish oils as EPA and DHA which are important components of cell membranes. EPA and DHA partially replace the n-6 fatty acids, particularly arachidonic acid (AA), in the cell membranes resulting in less substrate for the synthesis of inflammatory eicosanoids such as prostaglandin E2 (PGE2) and leukotriene B4 (Jump et al., 2002). PGE2 induces fever, pain, vasodilation and vascular permeability, while leukotriene B4, also produced by AA, is chemotactic for leukocytes and induces the release of reactive oxygen species by neutrophils and inflammatory cytokines (TNF-, IL-1b, IL-6) by macrophages. The ratio of n-6 to n-3 fatty acids also affects gene expression and intercellular communication (Bagga et al., 2003). PUFA rapidly modulate gene expression in different systems by regulating transcription factors such as PPAR, liver X receptors and sterol regulatory element binding protein-1c. These nuclear receptors play crucial roles in the regulation of fatty acid metabolism. Activation of PPAR leads to the increased expression of genes responsible for fatty acid oxidation such as acyl-CoA oxidase, fatty acyl-CoA synthetase and hydroxymethylglutaryl-CoAsynthase. Furthermore, action of PPAR inhibits inflammatory genes by breaking down inflammatory eicosanoids and interfering with transcription factors such as NF-kB. These include TNF-, IL-1b, IL-6, IL-8, cyclooxygenase-2, vascular cell adhesion molecule-1, inducible NO synthase, matrix metalloproteinases and acute-phase proteins (Calder et al., 2006). Currently, the western diet is very high in n-6 fatty acids. NEFA and Trans fats from margarines, fast food, snack food and fried food markedly increase inflammatory biomarkers including CRP and IL-6. Dietary modification in favour of n-3 fatty acids would rebalance the ratio of n-6 to n-3 fatty acids and have beneficial effects on the chronic inflammatory state (Oliver et al., 2010). The Mediterranean diet would be particularly suitable as it is rich in fruit, vegetables, whole-grains, legumes nuts, fish and low-fat dairy products which have been shown to be anti-inflammatory (Kastorini et al., 2011). Several micronutrients have also been shown to attenuate inflammation. In particular, Vitamin C, D and E have potent anti-inflammatory effects. Vitamin C and E have antioxidant properties while Vitamin D may inhibit TNF- and immune cell propagation (Rizzo et al., 2007, Stivelman et al., 2012). Studies have also evidenced the anti-inflammatory effects of tea, particularly green tea which contains the compound epigallocatechin-3-gallate. However, it should be noted that these effects are modest at best (Yan et al., 2012). Resveritrol, a compound found in red wine, has led to a flurry of studies due counterintuitive finding by Bianco-Colio et al. in 2000. Resveritrol was found to attenuate NF-kB levels, part of the IKK

pathway involved in insulin dysregulation (Liu et al., 2008). The Mediterranean diet also includes moderate red wine consumption which is thought to enhance the beneficial effects of this diet. Conclusion Visceral obesity and insulin resistance are predisposing factors for the development of type 2 diabetes, non-alcoholic fatty liver disease and CVD. Adipose tissue is biologically active and produces chemical messengers and cytokines such as TNF- and IL-6 which induce a state of low grade inflammation that contributes to macrophage accumulation leading to insulin resistance in adipose tissue, liver, and muscle. The transition from insulin-sensitive to insulin-resistant adipose tissue is correlated with a switch in macrophage polarity from an alternatively activated (M2) to a classically activated (M1) phenotype. Visceral obesity, as the main contributor to insulin resistance is a modifiable risk factor which through therapeutic lifestyle changes, with an emphasis on weight reduction, constitutes first-line treatment of this disorder.

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