Over the last decade, an abundance of evidence has emerged

demonstrating a close link between metabolism and immunity. It is

now clear that obesity is associated with a state of chronic low-level
inflammation. In this article, we discuss the molecular and cellular
underpinnings of obesity-induced inflammation and the signaling
pathways at the intersection of metabolism and inflammation that
contribute to diabetes. We also consider mechanisms through which
the inflammatory response may be initiated and discuss the reasons
for the inflammatory response in obesity. We put forth for
consideration some hypotheses regarding important unanswered
questions in the field and suggest a model for the integration of
inflammatory and metabolic pathways in metabolic disease.

Inflammation, stress, and diabetes

Survival of multicellular organisms depends on the ability to fight

infection and heal damage and the ability to store energy for times
of low nutrient availability or high energy need. Metabolic and
immune systems are therefore among the most basic requirements
across the animal kingdom, and many nutrient and pathogen-
sensing systems have been highly conserved from organisms such
as Caenorhabditis elegans and Drosophila to mammals. Perhaps not
surprisingly, metabolic and immune pathways have also evolved to
be closely linked and interdependent. Many hormones, cytokines,
signaling proteins, transcription factors, and bioactive lipids can
function in both metabolic and immune roles. In addition to using
some of the same cellular machinery, metabolic and immune
systems also regulate each other. The normal inflammatory
response relies upon metabolic support, and energy redistribution,
particularly the mobilization of stored lipid, plays an important role
in fighting infection during the acute-phase response (1). The basic
inflammatory response thus favors a catabolic state and suppresses
anabolic pathways, such as the highly conserved and powerful
insulin signaling pathway.

The integration of metabolism and immunity, which under normal

conditions is beneficial for the maintenance of good health, can
become deleterious under conditions of metabolic challenge, as
exemplified by the immunosuppression characteristic of
malnourished or starving individuals (13). Famine has been a
prominent hazard to human health throughout history, and for
thousands of years the link between infection and poor nutrition has
been well recognized. Today this threat is as widespread as ever,
and there are approximately 1 billion undernourished individuals
worldwide (3). In the past century, however, the pendulum has also
swung in the opposite direction, and now as many if not more
people are overweight or obese (4). With the advent of this chronic
metabolic overload, a new set of problems and complications at the
intersection of metabolism and immunity has emerged, including
the obesity-linked inflammatory diseases diabetes, fatty liver
disease, airway inflammation, and atherosclerosis (5).

There is now a wealth of evidence indicating close ties between

metabolic and immune systems. Among the many reasons to
maintain a healthy weight is the emerging paradigm that metabolic
imbalance leads to immune imbalance, with starvation and
immunosuppression on one end of the spectrum and obesity and
inflammatory diseases on the other end (Figure 1). In this article, we
will discuss the molecular and cellular links between metabolism
and inflammation, particularly in the context of obesity and
diabetes. Common inflammatory mediators, stress responses, and
signaling pathways will be highlighted. Finally, we will consider the
origin of and the reasons for the inflammatory response in obesity.

Figure 1
Metabolism and immunity are closely linked. Both
overnutrition and undernutrition have implications for
immune function. Starvation and malnutrition can suppress
immune function and increase susceptibility to infections. Obesity
is associated with a state of aberrant immune activity and
increasing risk for associated inflammatory diseases, including
atherosclerosis, diabetes, airway inflammation, and fatty liver
disease. Thus, optimal nutritional and metabolic homeostasis is an
important part of appropriate immune function and good health.

Obesity is characterized by inflammation

Factors at the crossroads of inflammation and metabolic disease. A

little more than a decade ago, the first molecular link between
inflammation and obesity TNF- was identified when it was
discovered that this inflammatory cytokine is overexpressed in the
adipose tissues of rodent models of obesity (6, 7). As is the case in
mice, TNF- is overproduced in the adipose as well as muscle
tissues of obese humans (810). Administration of recombinant TNF-
to cultured cells or to whole animals impairs insulin action, and
obese mice lacking functional TNF- or TNF receptors have
improved insulin sensitivity compared with wild-type counterparts
(6, 11). Thus, particularly in experimental models, it is clear that
overproduction of TNF- in adipose tissue is an important feature of
obesity and contributes significantly to insulin resistance.

It rapidly became clear, however, that obesity is characterized by a

broad inflammatory response and that many inflammatory
mediators exhibit patterns of expression and/or impact insulin
action in a manner similar to that of TNF- during obesity, in
animals ranging from mice and cats to humans (1214).
Transcriptional profiling studies have revealed that inflammatory
and stress-response genes are among the most abundantly
regulated gene sets in adipose tissue of obese animals (1517). A
list of many of these genes, which have been identified through a
variety of approaches, is provided in Table 1.

Table 1
Factors that mediate the intersection of metabolism
and immunity

In addition to inflammatory cytokines regulating metabolic

homeostasis, molecules that are typical of adipocytes, with well-
established metabolic functions, can regulate the immune response.
Leptin is one such hormone that plays important roles in both
adaptive and innate immunity, and both mice and humans lacking
leptin function exhibit impaired immunity (1820). Indeed, reduced
leptin levels may be responsible, at least in part, for
immunosuppression associated with starvation, as leptin
administration has been shown to reverse the immunosuppression
of mice starved for 48 hours (21). Adiponectin, resistin, and visfatin
are also examples of molecules with immunological activity that are
produced in adipocytes (2226).

Finally, lipids themselves also participate in the coordinate

regulation of inflammation and metabolism. Elevated plasma lipid
levels are characteristic of obesity, infection, and other
inflammatory states. Hyperlipidemia in obesity is responsible in part
for inducing peripheral tissue insulin resistance and dyslipidemia
and contributes to the development of atherosclerosis. It is
interesting to note that metabolic changes characteristic of the
acute-phase response are also proatherogenic; thus, altered lipid
metabolism that is beneficial in the short term in fighting against
infection is harmful if maintained chronically (1). The critical
importance of bioactive lipids is also evident in their regulation of
lipid-targeted signaling pathways through fatty acidbinding
proteins (FABPs) and nuclear receptors (see Regulation of
inflammatory pathways, below).

Macrophages and the link between inflammation and

metabolism. The high level of coordination of inflammatory and
metabolic pathways is highlighted by the overlapping biology and
function of macrophages and adipocytes in obesity (Figure 2). Gene
expression is highly similar; macrophages express many, if not the
majority of adipocyte gene products such as the
adipocyte/macrophage FABP aP2 (also known as FABP4) and PPAR,
while adipocytes can express many macrophage proteins such as
TNF-, IL-6, and MMPs (6, 2729). Functional capability of these 2
cell types also overlaps. Macrophages can take up and store lipid to
become atherosclerotic foam cells. Preadipocytes under some
conditions can exhibit phagocytic and antimicrobial properties and
appear to even be able to differentiate into macrophages in the
right environment, which suggests a potential immune role for
preadipocytes (30, 31). Furthermore, macrophages and adipocytes
colocalize in adipose tissue in obesity. The recent finding that
obesity is characterized by macrophage accumulation in white
adipose tissue has added another dimension to our understanding
of the development of adipose tissue inflammation in obesity
(16, 17). Macrophages in adipose tissue are likely to contribute to
the production of inflammatory mediators either alone or in concert
with adipocytes, which suggests a potentially important influence of
macrophages in promoting insulin resistance. However, no direct
evidence has been offered to establish this connection thus far.

Figure 2
Lipids and inflammatory mediators: integration of
metabolic and immune responses in adipocytes and macrophages
through shared mechanisms. Under normal conditions, adipocytes
store lipids and regulate metabolic homeostasis, and macrophages
function in the inflammatory response, although each cell type has
the capacity to perform both functions. In obesity, adipose tissue
becomes inflamed, both via infiltration of adipose tissue by
macrophages and as a result of adipocytes themselves becoming
producers of inflammatory cytokines. Inflammation of adipose
tissue is a crucial step in the development of peripheral insulin
resistance. In addition, in proatherosclerotic conditions such as
obesity and dyslipidemia, macrophages accumulate lipid to
become foam cells. Adipocytes and macrophages share common
features such as expression of cytokines, FABPs, nuclear hormone
receptors, and many other factors. As evidenced by genetic loss-
of-function models, adipocyte/macrophage FABPs modulate both
lipid accumulation in adipocytes and cholesterol accumulation in
macrophages, as well as the development of insulin resistance and
atherosclerosis. PPAR and LXR pathways oppose inflammation
and promote cholesterol efflux from macrophages and lipid storage
in adipocytes.

In terms of the immune response, integration between macrophages

and adipocytes makes sense, given that both cell types participate
in the innate immune response: macrophages in their role as
immune cells by killing pathogens and secreting inflammatory
cytokines and chemokines; and adipocytes by releasing lipids that
may modulate the inflammatory state or participate in
neutralization of pathogens. While it is not yet known whether
macrophages are drawn to adipose tissue in other inflammatory
conditions, it is conceivable that macrophage accumulation in
adipose tissue is a feature not only of obesity, but of other
inflammatory states as well.

Inflammatory pathways to insulin resistance

As discussed above, it is now apparent that obesity is associated

with a state of chronic, low-grade inflammation, particularly in white
adipose tissue. How do inflammatory cytokines and/or fatty acids
mediate insulin resistance? How do the stresses of obesity manifest
inside of cells? In recent years, much has been learned about the
intracellular signaling pathways activated by inflammatory and
stress responses and how these pathways intersect with and inhibit
insulin signaling.

Insulin affects cells through binding to its receptor on the surface of

insulin-responsive cells. The stimulated insulin receptor
phosphorylates itself and several substrates, including members of
the insulin receptor substrate (IRS) family, thus initiating
downstream signaling events (32, 33). The inhibition of signaling
downstream of the insulin receptor is a primary mechanism through
which inflammatory signaling leads to insulin resistance. Exposure
of cells to TNF- or elevated levels of free fatty acids stimulates
inhibitory phosphorylation of serine residues of IRS-1 (3436). This
phosphorylation reduces both tyrosine phosphorylation of IRS-1 in
response to insulin and the ability of IRS-1 to associate with the
insulin receptor and thereby inhibits downstream signaling and
insulin action (35, 37, 38).

Recently it has become clear that inflammatory signaling pathways

can also become activated by metabolic stresses originating from
inside the cell as well as by extracellular signaling molecules. It has
been demonstrated that obesity overloads the functional capacity of
the ER and that this ER stress leads to the activation of
inflammatory signaling pathways and thus contributes to insulin
resistance (3941). Additionally, increased glucose metabolism can
lead to a rise in mitochondrial production of ROS. ROS production is
elevated in obesity, which causes enhanced activation of
inflammatory pathways (42, 43).

Several serine/threonine kinases are activated by inflammatory or

stressful stimuli and contribute to inhibition of insulin signaling,
including JNK, inhibitor of NF-B kinase (IKK), and PKC- (44). Again,
the activation of these kinases in obesity highlights the overlap of
metabolic and immune pathways; these are the same kinases,
particularly IKK and JNK, that are activated in the innate immune
response by Toll-like receptor (TLR) signaling in response to LPS,
peptidoglycan, double-stranded RNA, and other microbial products
(45). Hence it is likely that components of TLR signaling pathways
will also exhibit strong metabolic activities.
JNK. The 3 members of the JNK group of serine/threonine kinases,
JNK-1, -2, and -3, belong to the MAPK family and regulate multiple
activities in development and cell function, in large part through
their ability to control transcription by phosphorylating activator
protein1 (AP-1) proteins, including c-Jun and JunB (46). JNK has
recently emerged as a central metabolic regulator, playing an
important role in the development of insulin resistance in obesity
(47). In response to stimuli such as ER stress, cytokines, and fatty
acids, JNK is activated, whereupon it associates with and
phosphorylates IRS-1 on Ser307, impairing insulin action
(36, 39, 48). In obesity, JNK activity is elevated in liver, muscle, and
fat tissues, and loss of JNK1 prevents the development of insulin
resistance and diabetes in both genetic and dietary mouse models
of obesity (47). Modulation of hepatic JNK1 in adult animals also
produces systemic effects on glucose metabolism, which
underscores the importance of this pathway in the liver (49). The
contribution of the JNK pathway in adipose, muscle, or other tissues
to systemic insulin resistance is currently unclear. In addition, a
mutation in JNK-interacting protein1 (JIP1), a protein that binds JNK
and regulates its activity, has been identified in diabetic humans
(50). The phenotype of the JIP1 loss-of-function model is very similar
to that of JNK1 deficiency in mice, with reduced JNK activity and
increased insulin sensitivity (51). Interestingly, the JNK2 isoform
plays a significant nonredundant role in atherosclerosis (52), though
apparently not in type 2 diabetes. Recent studies in mice
demonstrate that JNK inhibition in established diabetes or
atherosclerosis might be a viable therapeutic avenue for these
diseases in humans (52, 53).

PKC and IKK. Two other inflammatory kinases that play a large role
in counteracting insulin action, particularly in response to lipid
metabolites, are IKK and PKC-. Lipid infusion has been
demonstrated to lead to a rise in levels of intracellular fatty acid
metabolites, such as diacylglycerol (DAG) and fatty acyl CoAs. This
rise is correlated with activation of PKC- and increased Ser307
phosphorylation of IRS-1 (54). PKC- may impair insulin action by
activation of another serine/threonine kinase, IKK, or JNK (55).
Other PKC isoforms have also been reported to be activated by lipids
and may also participate in inhibition of insulin signaling (56).

IKK can impact on insulin signaling through at least 2 pathways.

First, it can directly phosphorylate IRS-1 on serine residues (34, 57).
Second, it can phosphorylate inhibitor of NF-B (IB), thus activating
NF-B, a transcription factor that, among other targets, stimulates
production of multiple inflammatory mediators, including TNF- and
IL-6 (58). Mice heterozygous for IKK are partially protected against
insulin resistance due to lipid infusion, high-fat diet, or genetic
obesity (59, 60). Moreover, inhibition of IKK in human diabetics by
high-dose aspirin treatment also improves insulin signaling,
although at this dose, it is not clear whether other kinases are also
affected (61). Recent studies have also begun to tease out the
importance of IKK in individual tissues or cell types to the
development of insulin resistance. Activation of IKK in liver and
myeloid cells appears to contribute to obesity-induced insulin
resistance, though this pathway may not be as important in muscle
(6264).

Other pathways. In addition to serine/threonine kinase cascades,

other pathways contribute to inflammation-induced insulin
resistance. For example, at least 3 members of the SOCS family,
SOCS1, -3, and -6, have been implicated in cytokine-mediated
inhibition of insulin signaling (6567). These molecules appear to
inhibit insulin signaling either by interfering with IRS-1 and IRS-2
tyrosine phosphorylation or by targeting IRS-1 and IRS-2 for
proteosomal degradation (65, 68). SOCS3 has also been
demonstrated to regulate central leptin action, and both whole body
reduction in SOCS3 expression (SOCS3 ) and neural SOCS3
+/

disruption result in resistance to high-fat dietinduced obesity and

insulin resistance (69, 70).

Inflammatory cytokine stimulation can also lead to induction of

iNOS. Overproduction of nitric oxide also appears to contribute to
impairment of both muscle cell insulin action and cell function in
obesity (71, 72). Deletion of iNOS prevents impairment of insulin
signaling in muscle caused by a high-fat diet (72). Thus, induction of
SOCS proteins and iNOS represent 2 additional and potentially
important mechanisms that contribute to cytokine-mediated insulin
resistance. It is likely that additional mechanisms linking
inflammation with insulin resistance remain to be uncovered.

Regulation of inflammatory pathways

Lipids and lipid targets. The role of lipids in metabolic disease is

complex. As discussed above, hyperlipidemia leads to increased
uptake of fatty acids by muscle cells and production of fatty acid
metabolites that stimulate inflammatory cascades and inhibit insulin
signaling (54). On the other hand, intracellular lipids can also be
antiinflammatory. Ligands of the liver X receptor (LXR) and PPAR
families of nuclear hormone receptors are oxysterols and fatty
acids, respectively, and activation of these transcription factors
inhibits inflammatory gene expression in macrophages and
adipocytes, in large part through suppression of NF-B (7379).

LXR function is also regulated by innate immune pathways.

Signaling from TLRs inhibits LXR activity in macrophages, causing
enhanced cholesterol accumulation and accounting, at least in part,
for the proatherogenic effects of infection (80). Indeed, lack of
MyD88, a critical mediator of TLR signaling, reduces atherosclerosis
in apoE mice (81). Interestingly, despite the inhibitory effects of
/

TLR signaling on LXR cholesterol metabolism, LXR appears to be

necessary for the complete response of macrophages to infection. In
the absence of LXR, macrophages undergo accelerated apoptosis
and are thus unable to appropriately respond to infection (82).
Unliganded PPAR also seems to have proinflammatory functions,
mediated at least in part through its association with the
transcriptional repressor B cell lymphoma 6 (BCL-6) (83).

The activity of these lipid ligands is influenced by cytosolic FABPs.

Animals lacking the adipocyte/macrophage FABPs ap2 and mal1 are
strongly protected against type 2 diabetes and atherosclerosis, a
phenotype reminiscent of that of thiazolidinedione-treated (TZD-
treated) mice and humans (27, 84, 85). One mechanism for this
phenotype is potentially related to the availability of endogenous
ligands for these receptors that stimulate storage of lipids in
adipocytes and suppress inflammatory pathways in macrophages
(86). In general, it appears that location in the body, the
composition of the surrounding cellular environment, and coupling
to target signaling pathways are critical for determining whether
lipids promote or suppress inflammation and insulin resistance.
Accumulation of cholesterol in macrophages promotes
atherosclerosis and of lipid in muscle and liver promotes insulin
resistance, while, as seen in TZD-treated and FABP-deficient mice, if
lipids are forced to remain in adipose tissue, insulin resistance in the
context of obesity can be reduced (85). Thus, lipids and their targets
clearly play both metabolic and inflammatory roles; however, the
functions that they assume are dependent on multiple factors.

Pharmacological manipulation of inflammation. In corroboration of

genetic evidence in mice that loss of inflammatory mediators or
signaling molecules prevents insulin resistance (11, 47, 59),
pharmacological targeting of inflammatory pathways also improves
insulin action. Effective treatment has been demonstrated both with
inhibitors of inflammatory kinases and with agonists of relevant
transcription factors. As discussed above, salicylates promote insulin
signaling by inhibiting inflammatory kinase cascades within the cell.
Through inhibition of IKK and possibly other kinases, salicylates are
able to improve glucose metabolism in both obese mice and
diabetic humans (53, 55, 74). Targeting of JNK using a synthetic
inhibitor and/or an inhibitory peptide has been demonstrated to
improve insulin action in obese mice and reduce atherosclerosis in
the apoE-deficient rodent model (52, 53). These results directly
demonstrate the therapeutic potential of JNK inhibitors in diabetes.

Synthetic ligands have been produced to all 3 PPAR isoforms as well

as LXR-, though only PPAR and PPAR ligands have been
approved for clinical treatment (87, 88). TZDs, high-affinity ligands
of PPAR, which are given clinically as insulin-sensitizing agents,
likely improve insulin action through multiple mechanisms, including
both activating lipid metabolism and reducing production of
inflammatory mediators such as TNF- (85, 8993). Synthetic PPAR
ligands, fibrates, are used to treat hyperlipidemia. These drugs
appear to work predominantly through stimulation of fatty acid
oxidation, though they also have antiinflammatory actions that
contribute to their effects (87, 94). LXR ligands have been
demonstrated to improve glucose metabolism in experimental
animals (88), and it remains to be seen whether suppression of
inflammation contributes to this action.

In targeting inflammation to treat insulin resistance and diabetes, it

is possible that seeking inhibitors for individual inflammatory
mediators may not be a maximally effective strategy, as other
redundant components may be sufficient to continue to propagate
inflammatory pathways. For example, targeting individual
inflammatory cytokines may not be highly effective, whereas
targeting the inflammatory kinases JNK and IKK generates a robust
antidiabetic action because these factors integrate signals from
multiple inflammatory mediators. On the other hand, if a more
central process or mediator can be identified, this may provide an
even more attractive target. The ER stress pathway could potentially
be one such central process, in that this pathway is able to activate
both JNK and IKK; thus, inhibiting the ER stress response through
addition of chaperones or other mechanisms could potentially
disable both of these arms of the inflammatory response and rescue
insulin action (39). It has recently been demonstrated that mice in
which the chaperone ORP150 is transgenically or adenovirally
overexpressed exhibited reduced ER stress and improved insulin
tolerance compared with controls, whereas reduction of the
expression of this molecule in liver results in increased ER stress and
insulin resistance (40, 41).

Origin of inflammation in obesity

While we are now aware of many of the inflammatory factors that

mediate insulin resistance and have some understanding of the
intracellular pathways involved, there is still much that remains
poorly understood. Crucial questions that are currently open regard
the initiation of the inflammatory response. Is inflammation the
primary event linking obesity with insulin resistance, or does the
inflammatory response begin only after the onset of resistance to
insulin? How and why does the body initiate an inflammatory
response to obesity? Does obesity per se induce an inflammatory
response, or is inflammation initiated as a secondary event by
hyperlipidemia or hyperglycemia?

In reviewing the facts, it is fairly clear that obesity promotes states

of both chronic low-grade inflammation and insulin resistance.
However, even in the absence of obesity, infusion of animals with
inflammatory cytokines or lipids can cause insulin resistance (54).
Additionally, humans with some other chronic inflammatory
conditions are at increased risk for diabetes; for example, about
one-third of patients with chronic hepatitis C develop type 2
diabetes, and elevated TNF- levels are implicated in this link
(95, 96). Rheumatoid arthritis also predisposes patients to diabetes
and particularly cardiovascular disease, and some evidence
indicates a link between inflammatory lung diseases and risk of
cardiovascular disease and diabetes (9799). Finally, removal of
inflammatory mediators or pathway components, such as TNF-,
JNK, and IKK, protects against insulin resistance in obese mouse
models, and treatment of humans with drugs that target these
pathways, such as salicylates, improves insulin sensitivity
(6, 11, 47, 59, 61). Thus, the available evidence strongly suggests
that type 2 diabetes is an inflammatory disease and that
inflammation is a primary cause of obesity-linked insulin resistance,
hyperglycemia, and hyperlipidemia rather than merely a
consequence (Figure 3).

Figure 3
Nutrient and pathogen sensing or response systems
have important overlapping features, and their modulation by
obesity or infection can lead to overlapping physiological
outcomes. For example, the chronic inflammation of obesity leads
to elevated plasma lipid levels and the development of insulin
resistance, eventually resulting in fatty liver disease,
atherosclerosis, and diabetes. Infection typically leads to a more
transient and robust inflammatory response and short-term
hyperlipidemia that aids in the resolution of the infection. In some
circumstances of chronic infection, however, insulin resistance,
diabetes, and atherosclerosis can result.

But how does the inflammatory response begin? Though this

question cannot currently be answered, we can suggest some
reasonable speculations based on the available data. It seems likely
that the inflammatory response is initiated in the adipocytes
themselves, as they are the first cells affected by the development
of obesity, or potentially in neighboring cells that may be affected
by adipose growth. How might expanding adipocytes trigger an
inflammatory response?

One mechanism that, based on newly emerging data, appears to be

of central importance is the activation of inflammatory pathways by
ER stress. Obesity generates conditions that increase the demand
on the ER (3941). This is particularly the case for adipose tissue,
which undergoes severe changes in tissue architecture, increases in
protein and lipid synthesis, and perturbations in intracellular
nutrient and energy fluxes. In both cultured cells and whole animals,
ER stress leads to activation of JNK and thus contributes to insulin
resistance (39). Interestingly, ER stress also activates IKK and thus
may represent a common mechanism for the activation of these 2
important signaling pathways (100).

A second mechanism that may be relevant in the initiation of

inflammation in obesity is oxidative stress. Due to increased delivery
of glucose to adipose tissue, endothelial cells in the fat pad may
take up increasing amounts of glucose through their constitutive
glucose transporters. Increased glucose uptake by endothelial cells
in hyperglycemic conditions causes excess production of ROS in
mitochondria, which inflicts oxidative damage and activates
inflammatory signaling cascades inside endothelial cells (101).
Endothelial injury in the adipose tissue might attract inflammatory
cells such as macrophages to this site and further exacerbate the
local inflammation. Hyperglycemia also stimulates ROS production
in adipocytes, which leads to increased production of
proinflammatory cytokines (42).

Why inflammation?

Perhaps one of the most difficult questions to answer is why obesity

elicits an inflammatory response. Why, if the ability to store excess
energy has been preserved through the course of evolution, does
the body react in a manner that is harmful to itself? We hypothesize
that this reaction is tied to the interdependency of metabolic and
immune pathways.

Could obesity-induced inflammation simply be a side effect of this

interaction that was never selected against since chronic obesity
and its associated disorders have been so rare over time for people
in their reproductive years? Perhaps the stresses of obesity are
similar enough to the stresses of an infection that the body reacts to
obesity as it would to an infection. For example, in both infection
and obesity, intracellular stress pathways such as the JNK and IKK
NF-B pathways are activated. Could these pathways be activated
by similar mechanisms in both conditions? One mechanism that
appears to be critical for initiation of this response in both situations
is ER stress. During viral infection, stress pathways are activated by
an excess of viral proteins in the ER (102). Similarly, the demands of
obesity also result in an overloaded ER and activation of these
pathways (39). Another scenario might be related to the capturing
of components of the insulin-signaling pathway by microorganisms.
Some pathogens activate host intracellular signaling cascades,
including the PI3K-Akt pathway, which is also critical for insulin
signaling (102). Perhaps in a situation in which this pathway
becomes overstimulated by an increased need to take up glucose,
the cell begins to interpret the signal as an indication of infection
and responds by resisting the anabolic insulin signal and instead
activating catabolic and inflammatory pathways.

On the other hand, perhaps the inflammatory response to obesity is

not simply an undesirable byproduct, but rather a homeostatic
mechanism to prevent the organism from reaching a point at which
excess fat accumulation impairs mobility or otherwise diminishes
fitness. Lipid storage and accumulation of fat weight require
anabolic processes, exemplified by insulin action, whereas
inflammation stimulates catabolism, including lipolysis from
adipocytes. It is conceivable that mechanisms such as the activation
of catabolism via inflammation (and hence resistance to anabolic
signals) may be an attempt to keep body weight within acceptable
bounds. While there is no available experimental evidence that
addresses the role of low-grade inflammation in such homeostasis,
some support for this idea can be seen in findings that
experimentally induced local inflammation or insulin resistance in
adipose tissue, such as that in adipose-specific insulin receptor
knockout mice and adipose-specific TNF transgenic mice, is
metabolically favorable, resulting in a lean phenotype and systemic
insulin sensitivity (103, 104).

Conclusions

Our understanding of the characteristics of inflammation in obesity

and the mechanisms by which this inflammation contributes to
insulin resistance has been increasing rapidly over the last decade,
such that we can now suggest a synthesized model (Figure 4). While
it is clear that inhibition of insulin receptor signaling pathways is a
central mechanism through which inflammatory and stress
responses mediate insulin resistance, it is likely that other relevant
pathways, molecules, and alternative mechanisms involved in this
interaction have yet to be uncovered. Of particular interest is the
role of alterations in mitochondrial function in diabetes. While we did
not cover this topic in this article, the reader is referred to an
excellent recent review for more information (105).

Figure 4
Model of overlapping metabolic and inflammatory
signaling and sensing pathways in adipocytes or macrophages.
Inflammatory pathways can be initiated by extracellular mediators
such as cytokines and lipids or by intracellular stresses such as ER
stress or excess ROS production by mitochondria. Signals from all
of these mediators converge on inflammatory signaling pathways,
including the kinases JNK and IKK. These pathways lead to the
production of additional inflammatory mediators through
transcriptional regulation as well as to the direct inhibition of
insulin signaling. Other pathways such as those mediated through
 the SOCS proteins and iNOS are also involved in inflammation-
mediated inhibition of insulin action. Opposing the inflammatory
pathways are transcription factors from the PPAR and LXR families,
which promote nutrient transport and metabolism and antagonize
inflammatory activity. More proximal regulation is provided by
FABPs, which likely sequester ligands of these transcription factors,
thus promoting a more inflammatory environment. The absence of
FABPs is antiinflammatory. The cell must strike a balance between
metabolism and inflammation. In conditions of overnutrition, this
becomes a particular challenge, as the very processes required for
response to nutrients and nutrient utilization, such as
mitochondrial oxidative metabolism and increasing protein
synthesis in the ER, can induce the inflammatory response. IR,
insulin receptor.

Another important question is whether genetic differences can

predispose some individuals to inflammation-mediated insulin
resistance. Several studies have reported associations between
diabetes and polymorphisms in the promoters of TNF- and IL-6
(106109). The most well-accepted polymorphism associated with
type 2 diabetes is found in the gene encoding PPAR (110). As it is a
transcription factor with some antiinflammatory activities, such as
suppressing the production of TNF-, one could imagine how altered
activity of PPAR could affect susceptibility to inflammation in
obesity. Similarly, genetic variations in the FABP, JNK, IKK, or ER
stress pathways or any other loci that modulate the extent of
inflammation and consequently insulin resistance could define the
risk of individuals for developing metabolic complication of obesity.

Finally, in addition to diabetes and cardiovascular disease,

inflammation is also known to be important for linking obesity to
airway inflammation and asthma, fatty liver disease, and possibly
cancer and other pathologies. Understanding the mechanisms
leading from obesity to inflammation will have important
implications for the design of novel therapies to reduce the
morbidity and mortality of obesity through the prevention of its
associated chronic inflammatory disorders.

Inflammation, stress, and diabetes

Kathryn E. Wellen and Gkhan S. Hotamisligil

First published May 2, 2005 - More info

Review

iabetologia
 June 2005, Volume 48, Issue 6, pp 10381050

An immune origin of type 2 diabetes?

Authors
Authors and affiliations
H. KolbEmail author
T. Mandrup-Poulsen

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1. 1.
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Review

First Online:

30 April 2005

DOI: 10.1007/s00125-005-1764-9

Cite this article as:

Kolb, H. & Mandrup-Poulsen, T. Diabetologia (2005) 48: 1038.

doi:10.1007/s00125-005-1764-9

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Abstract

Subclinical, low-grade systemic inflammation has been observed in patients with type 2
diabetes and in those at increased risk of the disease. This may be more than an
epiphenomenon. Alleles of genes encoding immune/inflammatory mediators are associated
with the disease, and the two major environmental factors the contribute to the risk of type 2
diabetesdiet and physical activityhave a direct impact on levels of systemic immune
mediators. In animal models, targeting of immune genes enhanced or suppressed the
development of obesity or diabetes. Obesity is associated with the infiltration and
proinflammatory activity of macrophages in adipose tissue, and immune mediators may be
important regulators of insulin resistance, mitochondrial function, ectopic lipid storage and
beta cell dysfunction or death. Intervention studies targeting these pathways would help to
determine the contribution of an activated innate immune system to the development of type
2 diabetes.

Keywords

AdipocytesBeta cellsIL-6Innate immunityInsulin

resistanceMacrophagesMetabolic syndromeMitochondriaType 2
diabetesSubclinical inflammation
Abbreviations

CRP

C-reactive protein

FasL

Fas ligand

FLIP

Fas-associated death domain protein-like IL-1 converting enzyme-

inhibitory protein

ICAM

intercellular adhesion molecule

MCP-1

monocyte chemotactic protein-1

NF-B

nuclear factor-B

PAI-1

plasminogen activator inhibitor-1

RANTES
 regulated upon activation normal T cell expressed and secreted

SOCS

suppressor of cytokine signalling

An erratum to this article can be found at http://dx.doi.org/10.1007/s00125-

005-1882-4

Introduction

Type 2 diabetes is caused by the failure of beta cells to compensate for insulin
resistance. Inflammatory or immunological factors are implicated in both
insulin resistance and beta cell failure, and this review will consider evidence
suggesting that these might be linked by a common mechanism.

Association of subclinical inflammation with type 2 diabetes

Subclinical systemic inflammation [16] and abnormalities of virtually all
systemic indicators of inflammation have been reported in type 2 diabetes.
These include increases in acute-phase proteins, cytokines and mediators
associated with endothelial activation (Table 1), although it is important to
note that the degree of immune activation is far below that seen in acute
infections. For example, median plasma C-reactive protein (CRP) levels were
only twice as high in patients with diabetes as compared with matched
control subjects in a population-based German cohort, and serum levels of
IL-6 largely overlapped (Fig. 1). We recently extended this study to include
chemokines (C. Herder et al., unpublished results). Interestingly, we
observed the selective upregulation of certain chemokines rather than a
uniform upregulation of all inflammatory mediators. Systemic
concentrations of RANTES (regulated upon activation normal T cell
expressed and secreted) and IL-8 were elevated, whereas levels of monocyte
chemotactic protein-1 (MCP-1) and eotaxin were not.

Table 1

Markers of subclinical inflammation in type 2 diabetes or the metabolic

syndrome

Acute-phase proteins
-1 Acid glycoprotein Haptoglobin

CRP Fibrinogen

Serum amyloid A protein Orosomucoid

Systemic cytokines/chemokines

IL-6 Soluble IL-6 receptor

TNF- Soluble TNF- receptors 1 and 2

IL-10 MIF

IL-1+IL-6 MCP-1

IL-18 RANTES

Blood/endothelial cell activation

Soluble ICAM-1 Soluble VCAM-1

Soluble E-selectin Soluble P-selectin

 von Willebrand factor Soluble CD40 ligand

TAFI PAI-1

t-PA Leucocyte count

All parameters exhibit increased levels in blood of patients with type 2

diabetes and/or in individuals with metabolic syndrome, except for systemic
levels of IL-10 which are reported to be decreased [102, 105, 106, 183188]

MIF Macrophage migration inhibitory factor, TAFI thrombin-activatable

fibrinolysis inhibitor, t-PA tissue plasminogen activator, VCAM-1 vascular cell
adhesion molecule-1

Fig. 1

Elevated systemic levels of CRP (a) and IL-6 (b) in type 2 diabetes.
Comparison of patients with type 2 diabetes (n=152) with non-diabetic
control subjects matched for age and sex (n=77) from a population-based
sample. Modified after Mller et al. [218] Boxand whisker plots show the
10th, 25th, 50th (median), 75th and 90th percentiles

The possibility that these inflammatory changes might be a consequence of

type 2 diabetes rather than a contributor to its development can be rejected
on two grounds. First, similar degrees of subclinical inflammation are seen in
subjects with IGT and those with overt type 2 diabetes (Table 1). Second,
prospective studies (Table 2) have reported subtle proinflammatory changes,
including raised leucocyte counts and modest increases in circulating
inflammatory mediators, many years before the diagnosis of type 2 diabetes
[722] and at a stage when few would be expected to have IGT or impaired
fasting blood glucose levels. Very high levels of CRP did not further increase
diabetes risk [17].
Table 2

Prospective studies of incident type 2 diabetes

Study Age at Number Follow- Incident Immunological

entry of up for diabetes risk factor
(years) subjects diabetes (n)

Atherosclerosis Risk 4564 12,330 7 years 1,335 Factor VIII

in Communities Study
(ARIC) [7, 8]
von Willenbrand
factor

Leucocyte count

Orosomucoid

Fibrinogen

Sialic acid

Serum albumin

Womens Health 45 27,628 4 years 188 CRP

Study (WHS) [9]

IL-6
Study Age at Number Follow- Incident Immunological
entry of up for diabetes risk factor
(years) subjects diabetes (n)

Cardiovascular Health 65 5,888 34 years 45 CRP

Study (CHS) [10]

Pima Indian 5 2,088 15 years 695 -globulin

Population [11]

Pima Indian 1850 272 5.5 years 54 Leucocyte count

Population [12]

West of Scotland 4564 5,974 4.9 years 127 CRP

Coronary Prevention
Study (WOSCOPS)
[13, 189]

National Health and 2574 8,352 20 years 878 Leucocyte count

Nutrition Survey
Epidemiological
follow-up Study
(NHANES I) [14]

Japanese male office 3559 2,953 6 years 154 (263 Leucocyte count
worker study [15] IFG)

Insulin Resistance 4069 1,047 5 years 144 PAI-1

Atherosclerosis Study
Study Age at Number Follow- Incident Immunological
entry of up for diabetes risk factor
(years) subjects diabetes (n)

(IRAS) [16]

Monitoring of Trends 4574 2,052 7.2 years 101 CRP

and Determinants in
Cardiovascular
Disease (MONICA)
Augsburg cohort
Study [17]

EPIC-Potsdam study 3565 27,548 2.3 years 188 IL-6 , IL-6+IL-1

[18]

Mexico City Diabetes 3564 1,244 6 years 190 CRP in women

Study [19] (metabolic only
syndrome)

Hong Kong 2574 228 IGT 2 years 21 CRP

Cardiovascular Risk 228 NGT
Factors Prevalence
Study [20]

Hoorn study [22] 279 6.4 years 54 CRP in men only

Nurses Health Study 3055 32,826 10 years 737 TNF- Rec 2

 Study Age at Number Follow- Incident Immunological
entry of up for diabetes risk factor
(years) subjects diabetes (n)

[21] IL-6

CRP

Genetic studies support a pathogenic role for immune mediators

Although low-grade inflammatory changes precede type 2 diabetes by many

years, immune activation might nonetheless simply reflect an underlying, but
unrelated disease process. One way of assessing whether immune reactivity
plays a causal or contributory role in the pathogenesis of type 2 diabetes is to
search for an association between diabetes risk and immune genes. The
number of immune genes identified as containing one or more alleles
associated with type 2 diabetes is steadily increasing. However, most studies
are small and are not population-based, and the reported associations have
yet to be confirmed in different populations. Nonetheless, it is worth noting
that alleles in HLA loci and in the genes encoding TNF-, TNF-, TNF-
receptor 80, IL-6, IL-6 receptor-, CRP, TGF- and plasminogen activator
inhibitor-1 (PAI-1) have been reported to be associated with type 2 diabetes
and/or the metabolic syndrome [2336]. Most of these alleles are functional
in that they modify the inflammatory response, and the concept of an
inflammatory contribution to the pathogenesis of type 2 diabetes would
indeed require functional alleles such as these to be associated with diabetes
risk.

Lessons from animal models

Another way of investigating the relationship between inflammatory immune
reactivity and type 2 diabetes is to study immune gene defects in animals to
determine whether these cause or prevent the development of diabetes.
While such studies do not allow firm conclusions to be drawn concerning the
pathogenesis of human diabetes, they can provide the necessary proof of
principle. Several of the immune genes associated with diabetes have been
studied in animal models and, as shown in Table 3, immune gene disruption
or transgenic overexpression in mice had a major effect on the risk of
developing insulin resistance or diabetes in response to a high-caloric diet
[3743]. A straightforward explanation is that, in these animal models, TNF-
, IL-6, intercellular adhesion molecule-1 (ICAM-1) or PAI-1 are either
directly or indirectly involved in the development of severe obesity and
diabetes. However, one important caveat is that, as previously observed [44],
the phenotype caused by a gene defect strongly depends on the overall
genetic background, i.e. a defective PAI-1 or ICAM-1 gene may not exhibit
diabetes- or obesity-regulating properties if introduced onto another genetic
background (S. Martin and H. Kolb, unpublished results). It should,
however, be acknowledged that immune genes do affect diabetes risk.

Table 3

Animal models that prove the link between inflammatory/immune genes and
type 2 diabetes

Inflammatory/immune defects that cause insulin resistance or type 2 diabetes in mice on a high-
caloric diet

ICAM-1 gene disruption [38]

CD11b gene disruption [38]

IL-6 gene disruption [39]

Inflammatory/immune defects that prevent insulin resistance or type 2 diabetes in mice on a

high-caloric diet

TNF-/TNF- receptors 1 and 2 gene disruption [37]

PAI-1 gene disruption [40, 41]

 PAI-1 gene overexpression [42]

Inducible nitric oxide synthase gene disruption [43]

Immune mechanisms in diabetes pathogenesis: insulin resistance

No randomised controlled trial has provided formal proof that high-caloric

diets and insufficient muscle work are the major environmental factors
promoting the pathogenesis of obesity and type 2 diabetes, and it is unlikely
that any such trial will ever be undertaken. The indirect evidence is, however,
overwhelming, and we will assume that this concept is valid.

Environmental factors seem to act via two major targets. One is the
processing of glucose, fatty acids and other metabolites, as regulated by
insulin and other hormones in the majority of tissues, and the other is beta
cell function. The resulting insulin resistance and impaired insulin secretion
precede the onset of hyperglycaemia by many years, if not decades [45, 46].
The hypothesis of an immune origin of type 2 diabetes is based on the
concept that immune inflammatory mediators are responsible for the effects
of these environmental factors on insulin resistance and beta cell function.
As depicted in Fig. 2, the metabolic concept of the pathogenesis of diabetes
considers that tissue function is directly affected by the toxic effect of excess
glucose, NEFA and triglycerides, probably mediated by increased oxidative
stress. The immunological concept assumes that the production of
proinflammatory immune mediators is an essential step in glucotoxicity and
lipotoxicity. Conversely, anti-inflammatory immune mediators such as IL-10
would be expected to counteract glucotoxicity and lipotoxicity.

Fig. 2

Metabolic vs immunologic concepts of the pathogenesis of type 2 diabetes.

The two major pathogenic factors causing type 2 diabetes appear to be
insulin resistance of major peripheral tissues and impairment and gradual
loss of beta cell function, both of which are closely associated with vascular
damage. The metabolic concept assumes a direct detrimental effect of high
levels of glucose and NEFA or triglycerides on target cells limited by the
functional capacity of mitochondria. The immunological concept suggests
that an essential step in macronutrient toxicity is the induction of
inflammatory mediators, which regulate mitochondrial function and damage
target cells. Without such an inflammatory response, excess macronutrient
supply (including advanced glycation and lipoxation end products) would not
be diabetogenic

In animal models, both insulin resistance and diabetes can result from
diverse genetic defects affecting the function of individual organs, including
liver, fat, muscle, islet and neuronal tissue [4767]. However, as described
above, insulin resistance may also result from defects in various
inflammatory/immune genes (Table 3). What mediates the effects of
environmental factors on insulin resistance? There are indications that
dietary effects may be immune mediated and that monocytes, endothelial
cells and other cell types respond to elevated concentrations of glucose or
NEFA by releasing inflammatory mediators, such as PAI-1, IL-6, TNF-,
soluble ICAM-1, prostaglandins, MCP-1 and IL-1 [6875].

These responses can be suppressed by experimental strategies aimed at

blocking the production or action of free radicals or superoxide
[69, 72, 73, 7679]. It has therefore been proposed that increased
mitochondrial activity accounts for increased oxidative stress, which, in turn,
causes the expression of several critical immune genes via redox-regulated
transcription factors, such as nuclear factor-B (NF-B) or stress kinases.
The recent observation of a close association between impaired
mitochondrial function and insulin resistance or type 2 diabetes supports
this concept [80, 81].

The upregulation of proinflammatory gene expression in response to high

levels of glucose or fat has also been observed in vivo within a few hours of
enteral uptake or parenteral administration of nutrients [8287].
Furthermore, levels of circulating immune mediators, such as IL-6 or IL-18,
released in healthy subjects in response to the macronutrient challenge were
similar to those seen in type 2 diabetes. An additional, interesting argument
is that western diets are usually rich in advanced glycation and lipoxation
end-products. Both are glucose-derived compounds that have been shown to
elicit a profound proinflammatory response in vitro as well as in vivo
[88, 89].

It may be argued that the inflammatory response observed is only an

epiphenomenon attributable to excess radical production in mitochondria,
whereas the consequences of impaired or unbalanced mitochondrial activity
relevant to diabetes are immediate functional defects in fat cells, hepatocytes,
beta cells or other cells [90]. The only available experimental evidence to
address this comes from animal studies. It has been shown that a high-
calorie diet does not induce insulin resistance if certain proinflammatory
genes, such as PAI-1 and TNF-, are non-functional [37, 41]. Furthermore,
deletion of other immune genes, such as ICAM-1, renders a high-caloric diet
prodiabetic [38]. The intercellular adhesion molecule ICAM-1 is not
expressed in mitochondria and is not considered to regulate mitochondrial
function. Conversely, immune or inflammatory mediators such as PAI-1
appear to have major effects on mitochondrial function and ectopic
triglyceride accumulation in non-adipocytes [41]. Many proinflammatory
genes are induced by the transcription factor NF-B. Impaired activation of
NF-B by deletion of the gene encoding IB kinase- in myeloid cells alone
protected mice from high-fat-diet-induced insulin resistance in liver and
muscle, indicating a key role for activated leucocytes [91]. We recently
observed that cytokines modulate the expression of uncoupling protein-2, a
major regulator of thermogenesis and substrate oxidation [92]. The capacity
of mitochondria to process large quantities of substrate may therefore be
modulated by low-grade inflammation.

The induction of low-grade inflammation by a high-caloric diet may also

occur via the concomitant growth of adipocytes. The observation that
systemic levels of many immune mediators are strongly correlated with BMI,
fat mass and/or waist circumference [93] has led to the assumption that
many circulating immune mediators originate from adipocytes; however, this
view may be too simple. Two recent studies in mice and humans provide
evidence that obese adipose tissue exhibits macrophage infiltration and that
these macrophages are a major source of inflammatory mediators [94, 95].
Infiltrated macrophages account for almost all TNF- expression and much
of the IL-6 expression in adipose tissue. It should be noted that the
upregulation of proinflammatory genes in macrophages occurs before
circulating insulin levels increase (a marker of insulin resistance). The
infiltration of adipose tissue by macrophages is strongly correlated with BMI
in humans, suggesting that fat accumulation in adipocytes triggers the influx
of macrophages and their activation. This may occur through the release of
chemokines from adipocytes [9496] and/or via the expression of stress
proteins on the fat cell surface [97, 98]. Hence, obesity would only result in
insulin resistance and type 2 diabetes if macrophage infiltration and
activationadipositisevolved and persisted.

How do proinflammatory immune mediators cause insulin resistance? Many

studies have analysed this question, and these will only be summarised here.
Immune mediators such as TNF- and IL-6 can directly interfere with
insulin signalling [99103], and the binding of these cytokines to their
cognate receptor on muscle cells or hepatocytes has been shown to induce an
 intracellular response that interferes with the ability of the insulin receptor
to phosphorylate its intracellular targets. The cellular response to insulin is
dampened in consequence. One well-described example of this is the
induction of the protein suppressor of cytokine signalling-3 (SOCS-3) by IL-6
in hepatocytes. This protein associates with the insulin receptor and
suppresses insulin-dependent receptor autophosporylation and IRS-1
phosphorylation [100]. SOCS-3 also binds to IRS-1 and IRS-2, leading to
their ubiquitination and proteasomal degradation [104]. Immune mediators
also affect insulin sensitivity indirectly by modulating the regulatory function
of fat, nerve or other cells, e.g. by influencing the release of leptin or by
activating the hypothalamicpituitaryadrenal axis [105109].

One final aspect of immune-mediated insulin resistance to consider is the

way in which physical exercise/muscle work might counteract insulin
resistance. Muscle work is intimately linked with the production of certain
immune mediators, and skeletal muscle expresses a large amount of IL-6,
which is released into the circulation in response to exercise [110112]. In
contrast, the expression of low levels of TNF- is unaltered [113]. The
production of IL-6 is modulated by the glycogen content of muscle tissue
[114], and IL-6 may also be released from the human brain during prolonged
exercise [115]. Muscle-derived IL-6 may have beneficial effects, at least
within a certain concentration range, since IL-6 inhibits low-grade TNF-
production and stimulates lipolysis and fat oxidation [116, 117]. Intra-
arterial acute infusion of IL-6 does not impair whole-body glucose disposal in
healthy humans [118]. Although IL-6 administration has been shown to
induce hepatic and skeletal muscle insulin resistance in mice [119], the fact
that IL-6 deficiency was associated with the development of diabetes in the
same species cannot be ignored (Table 3). In obese subjects, IL-6 levels in the
central nervous system are negatively correlated with fat mass, and
intracerebroventricular IL-6 treatment decreases body fat in rats [120].
Taken together, these findings suggest that the glucose-lowering effect of
exercise may indeed be immune mediated.

Immune mechanisms in diabetes pathogenesis: beta cell destruction

The other major issue in the pathogenesis of type 2 diabetes is whether and,
if so, how immune mediators are involved in the steady loss of beta cell
function which predates the onset of diabetes [121123]. Metabolic stress
resulting from a high-caloric diet and the concomitant detrimental effects of
increased glucose or NEFA concentrations on beta cells are considered major
contributors to beta cell loss [74, 122, 124127], which occurs mainly by
apoptosis [128, 129]. The question at issue is whether beta cell damage and
apoptosis are direct consequences of the increased mitochondrial generation
of oxygen radicals or whether immune/inflammatory mediators are
responsible (Fig. 3).

Fig. 3

A model for inflammatory beta cell dysfunction and apoptosis in (pre) type 2
diabetes. Metabolic stressors can cause beta cell dysfunction via increased
cytokine action or reduced cytokine antagonist action, and increased free
radical production. A reduced expression of the Fas/FasL signalling inhibitor
FLIP may accelerate this phenomenon. Toxic actions may be enhanced by
products of metabolically stressed endothelial cells and by increased systemic
levels of beta cell toxic immune mediators. IL-1 Ra IL-1 receptor
antagonist; ROS reactive oxygen species; EC endothelial cells

Evidence favouring oxidative stress as a mediator of beta cell apoptosis in

type 2 diabetic patients has recently been published [130], and lipid
peroxidation was shown to be increased in the islets of patients with type 2
diabetes as compared with control subjects. The islets of diabetic patients
contained less cytoplasmic Cu/Zn superoxide dismutase, and there was a
clear inverse correlation between oxidative DNA damage and islet beta cell
volume density in these patients.

There is controversy as to whether in vitro exposure of human islets to high

glucose levels leads directly to beta cell apoptosis [68, 131, 132]. High
glucose increased TUNEL staining (evidence of apoptosis) in a dose-
dependent manner, and increased expression of the Fas receptor, leading to
cleavage of pro-caspase 3 and activation of caspase 3. This probably occurred
through transactivation of Fas by Fas ligand (FasL) expressed constitutively
by neighbouring islet cells [68, 131, 132]. In contrast, glucose oxidation was
unaffected in human islets exposed to high glucose in vitro, and human islets
transplanted to hyperglycaemic nude mice did not exhibit ultrastructural
signs of apoptosis [68, 132]. One of the differences between the in vitro
studies cited above is in the method used to culture human islets. In the
former study, human islets were cultured on an extracellular matrix from
bovine corneal epithelial cells, whereas in the latter the islets were cultured
in free-floating organ cultures. Clarification is needed as to whether this
methodological difference affected the outcome of these and other studies,
and may explain discrepancies in the literature concerning the expression of
FasL on human beta cells [131, 133].
It is intriguing that glucose-stimulated IL-1 synthesis and secretion and high-
glucose-induced beta cell apoptosis were prevented by an IL-1 receptor
antagonist [134], although this observation requires independent
confirmation. IL-1 expression has also been detected in pancreases from type
2 diabetic patients, but not in control subjects, as well as in Psammomys
obesus fed a high-energy diet leading to hyperglycaemia [134]. In this model,
IL-1 expression in islet beta cells was reversed by the administration of
phlorizin, leading to normoglycaemia. It is surprising that IL-1, which usually
does not cause beta cell apoptosis in human islets [133, 134], induced
apoptosis in these experiments. It is not clear whether this relates to the
culture conditions, or to the secretion of cytokines such as TNF- or IFN- in
these particular islet preparations. A very recent study from the same group
suggested that an IL-1 receptor antagonist is a physiological regulator of beta
cell viability, since small interfering RNAs directed against the IL-1 receptor
antagonist increased the apoptotic rate, even at basal glucose levels at which
beta cell IL-1 production is low [135]. In the same study, leptin, an important
adipokine and a member of the IL-6 cytokine family, was shown to induce
beta cell apoptosis in human islets by reducing levels of IL-1 receptor
antagonist and increasing IL-1 synthesis and secretion [135].

The reduced level of the Fas-associated death domain protein-like IL-1

converting enzyme-inhibitory protein (FLIP) observed in the pancreases of
type 2 diabetic patients may also contribute to glucose-induced apoptosis
[136]. Interestingly, this inhibitor determines whether Fas-signalling will
lead to apoptosis or cell proliferation. This concept is consistent with the
observation that the signalling intermediates involved in glucose- and IL-
induced beta cell apoptosis in human islets are strikingly similar [137]. The
toxic actions of NEFA on beta cell function may be mediated by similar
pathways; several lines of evidence point to this. Exposure to NEFA causes
oxidative stress [76, 125, 127, 138141] followed by apoptosis [142], and IL-
1 potentiates NEFA toxicity [143]. Exogenous IL-1 or other toxic immune
mediators from the islet endothelium [144147] or from the circulation may
act in concert with dietary fatty acids to damage beta cells, although the
signalling pathways involved may differ in some respects. While cytokines
induce activation of NF-B and nitric-oxide-dependent endoplasmic
reticulum stress, NEFA induce endoplasmic reticulum stress independently
of NF-B and nitric oxide in beta cells [148]. Since recent studies have
questioned the role of nitric oxide in cytokine-induced beta cell destruction
in vivo [149], and have emphasised mitochondrial perturbation as an
important feature, the main effector mechanisms elicited by cytokines and
metabolic factors may not differ to a great extent.
 In conclusion, there is emerging, although controversial, evidence that
metabolic factorsparticularly glucose in (pre) type 2 diabetesmay
contribute to beta cell dysfunction and apoptosis. This is thought to occur via
metabolic stress leading to the synthesis of inflammatory mediators that
elicit intracellular responses that are largely similar to those involved in
immune-mediated beta cell destruction in type 1 diabetes.

Immune or inflammatory?

As described above, low-grade inflammation in (pre) type 2 diabetes is

generally considered to be a non-specific consequence of metabolic stress.
This type of inflammatory response would not require the infiltration of
inflamed tissues by (auto)antigen-reactive immune cellsthe hallmark of
classic inflammation. Although it is conceivable that inflammation is fuelled
by non-antigen-specific reactions, we would like to point out that a chronic
inflammatory state, such as that observed in (pre) type 2 diabetes, may be
driven by antigens, and that chronicity may result from deficient anti-
inflammatory feedback loops. Antigens known to be expressed on stressed
cells or released from damaged cells, notably stress proteins or certain lipid
compounds, are candidates for this role [97, 150152]. Such stress antigens
may drive inflammation in obese adipose tissue, islets or the vessel wall, and
heat shock protein 60 and oxidised lipids have already been identified in
animal models as antigens that either cause or maintain the atherosclerotic
disease process in the vessel wall [153155].

Limited data are available on islet histology in type 2 diabetes. Although a

decrease in beta cell volume, an increased number of alpha cells and the
deposition of islet amyloid have been reported, it is not known whether tissue
macrophages, dendritic cells or endothelial cells exhibit a proinflammatory
phenotype [128, 129, 139, 156158]. In diabetic patients, the presence of
extensive islet amyloidosis does not appear to be associated with the influx of
macrophages [159]. However, there are no data on the type of morphological
or inflammatory changes that occur in pancreatic islets prior to diabetes
onset, for example, in obese individuals with IGT.

Intervention studies
The classical treatment modalities for type 2 diabetes are diet and exercise
for weight reduction, and pharmacological intervention by oral
hypoglycaemic drugs or insulin, all of which affect the inflammatory state.
Weight reduction and/or physical exercise markedly reduce circulating levels
of inflammatory mediators such as CRP and IL-6 (Table 4), a response that
probably indicates the remission of macrophage-mediated inflammation in
adipose tissue as a consequence of altered fat cell metabolism. It could be
argued that the remission of systemic low-grade inflammation by lifestyle
changes is an epiphenomenon, but, once again, genetic studies imply a causal
relationship. For example, it was reported by the Finnish Diabetes
Prevention Study that the protective effect of lifestyle changes was associated
with polymorphisms in the promoters of the genes encoding TNF- and IL-6
[160].

Table 4

Interventions that have an impact on the inflammatory state

Inflammatory mediators whose concentrations are reduced by weight loss and/or physical
exercise [190207]

CRP, TNF-, soluble TNF- receptor 2, IL-6, IL-18, MCP-1, PAI-1, t-PA, soluble ICAM-1,
soluble VCAM-1, P-selectin

Inflammatory mediators whose concentrations are reduced by glucose-lowering drugs

[186, 188, 208217]

Sulphonylurea: TNF-

Metformin: CRP

Glitazones: CRP, SAA, TNF-, soluble CD40 ligand, PAI-1

Insulin: CRP, IL-1, IL-6, TNF-, soluble ICAM-1, MCP-1, PAI-1

SAA Serum amyloid A, t-PA tissue plasminogen activator, VCAM-1 vascular

cell adhesion molecule-1
 As shown in Table 4, all oral hypoglycaemic agents have anti-inflammatory
properties. It is therefore conceivable that a dampening of innate immune
reactivity contributes to their therapeutic effects and those of insulin. To
date, the preventive or therapeutic potential of anti-
inflammatory/immunosuppressive therapy has not been evaluated. Pilot
trials with antibodies directed against TNF- have not shown a beneficial
effect on insulin action, in contrast to the observations in mice [161164].
However, it is not known whether sufficiently high concentrations of TNF-
antagonist were reached in target tissues, or whether immune mediators
other than TNF- are more important for the induction of insulin resistance
in humans. Recent studies with TNF- infusion demonstrated its ability to
cause insulin resistance in vivo [165]. The results of therapeutic studies on
high-dose aspirin in type 2 diabetes patients are more encouraging: in
parallel with a reduction of systemic CRP levels there was a 25% reduction in
fasting blood glucose and an even larger decrease in serum triglyceride levels
[166].

A clinical trial has been launched to investigate the importance of

proinflammatory cytokines in the generation of insulin resistance and beta
cell failure in type 2 diabetes. This will test the effect of subcutaneous human
recombinant IL-1 receptor antagonist (100 mg/day) vs placebo in patients
with type 2 diabetes (collaboration between M. Donath, Division of
Endocrinology and Diabetes, University Hospital, Zurich, Switzerland and
The Steno Diabetes Centre, Denmark).

Low-grade inflammation and health

Cross-sectional and prospective studies in the general population, the

elderly, and centenarians have shown that mildly elevated levels of CRP and
proinflammatory cytokines are associated with, or predict, atherosclerosis,
myocardial infarction, stroke, depression and Alzheimers disease, and that
longevity is associated with decreased systemic inflammation [105, 167
171]. Here, again, polymorphisms in immune genes modulate risk, implying
a pathogenetic significance for immune gene products [171173]. Where
studied, the upregulation of inflammatory mediators was linked to increased
oxidative stress, impaired mitochondrial function and abnormal cholesterol
metabolism [174176]. Interventions targeting cholesterol metabolism or
oxidative stress also ameliorated inflammation [167, 177182]. We therefore
conclude that the metabolic concept and the immunological concept are
simply two views of the same process, seen from different angles.