Amanda J. Cox

Obesity, inflammation, and the gut microbiota

As the prevalence of obesity and associated disease continues to rise and concerns for the spiralling economic and social costs also escalate, innovative management strategies beyond primary prevention and traditional lifestyle interventions are urgently needed. The biological basis of disease is one avenue for further exploration in this context. Several key inflammatory markers have been consistently associated with both obesity and risk of adverse outcomes in obesity-associated diseases, which suggests that a persistent, low-grade, inflammatory response is a potentially modifiable risk factor. In this Review, we provide evidence supporting perturbation of the intestinal microbiota and changes in intestinal permeability as potential triggers of inflammation in obesity. Further characterisation of the mechanisms underpinning the triggers of such inflammatory responses in overweight and obese individuals could offer unique opportunities for intervention strategies to help ameliorate the risk of obesity-associated disease.

Oral administration of the probiotic Lactobacillus fermentum VRI-003 and mucosal immunity in endurance athletes

Objective To evaluate the ability of a probiotic Lactobacillus fermentum VRI-003 (PCC) to enhance the mucosal immune system of elite athletes. Design and setting A double-blind, placebo-controlled, crossover trial was conducted over a 4-month period of winter training. Participants 20 healthy elite male distance runners. Interventions PCC was given at a daily dose of 1.26×1010 as a freeze-dried powder in gelatin capsules. Placebo capsules contained an inert excipient. Main outcome measures Treadmill performance (monthly), mucosal and systemic immunity (monthly), training (daily) and illness (daily) were assessed. Serum cytokine levels, salivary IgA levels and incidence, duration and severity of respiratory tract infections were measured. Results Subjects reported less than half the number of days of respiratory symptoms during PCC treatment (30 days) compared with placebo (72 days, p<0.001). Illness severity was also lower for episodes occurring during the PCC treatment (p = 0.06). There were no significant differences in the mean change in salivary IgA and IgA1 levels, or in interleukin (IL)4 and IL12 levels, between treatments. However, PCC treatment elicited a twofold (p = 0.07) greater change in whole-blood culture interferon gamma (IFNγ) compared with placebo. No substantial changes in running performance measures were seen over the study period. Conclusions Prophylactic administration of PCC was associated with a substantial reduction in the number of days and severity of respiratory illness in a cohort of highly trained distance runners. Maintenance of IFNγ levels may be one mechanism underpinning the positive clinical outcomes.

Daily training with high carbohydrate availability increases exogenous carbohydrate oxidation during endurance cycling

We determined the effects of varying daily carbohydrate intake by providing or withholding carbohydrate during daily training on endurance performance, whole body rates of substrate oxidation, and selected mitochondrial enzymes. Sixteen endurance-trained cyclists or triathletes were pair matched and randomly allocated to either a high-carbohydrate group (High group; n = 8) or an energy-matched low-carbohydrate group (Low group; n = 8) for 28 days. Immediately before study commencement and during the final 5 days, subjects undertook a 5-day test block in which they completed an exercise trial consisting of a 100 min of steady-state cycling (100SS) followed by a 7-kJ/kg time trial on two occasions separated by 72 h. In a counterbalanced design, subjects consumed either water (water trial) or a 10% glucose solution (glucose trial) throughout the exercise trial. A muscle biopsy was taken from the vastus lateralis muscle on day 1 of the first test block, and rates of substrate oxidation were determined throughout 100SS. Training induced a marked increase in maximal citrate synthase activity after the intervention in the High group (27 vs. 34 micromol x g(-1) x min(-1), P < 0.001). Tracer-derived estimates of exogenous glucose oxidation during 100SS in the glucose trial increased from 54.6 to 63.6 g (P < 0.01) in the High group with no change in the Low group. Cycling performance improved by approximately 6% after training. We conclude that altering total daily carbohydrate intake by providing or withholding carbohydrate during daily training in trained athletes results in differences in selected metabolic adaptations to exercise, including the oxidation of exogenous carbohydrate. However, these metabolic changes do not alter the training-induced magnitude of increase in exercise performance.

Reversal in fatigued athletes of a defect in interferon γ secretion after administration of Lactobacillus acidophilus

Background: Fatigue and impaired performance in athletes is well recognised and has been loosely linked to “overtraining”. Reduced concentration of IgA in the saliva and increased shedding of Epstein Barr virus (EBV) have been associated with intense training in elite athletes. Objective: To determine whether athletes presenting with fatigue and impaired performance had an immune defect relevant to defective containment of EBV infection, and whether a probiotic preparation (Lactobacillus acidophilus) shown to enhance mucosal immunity in animal models could reverse any detected abnormality. Results: The fatigued athletes had clinical characteristics consistent with re-activation of EBV infection and significantly (p  =  0.02) less secretion of interferon (IFN) γ from blood CD4 positive T cells. After one month of daily capsules containing 2 × 1010 colony forming units of L acidophilus, secretion of IFNγ from T cells had increased significantly (p  =  0.01) to levels found in healthy control athletes. A significant (p  =  0.03) increase in salivary IFNγ concentrations in healthy control athletes after the one month course of L acidophilus demonstrated in man the capacity for this probiotic to enhance the mucosal IFNγ concentration. Conclusion: This is the first evidence of a T cell defect in fatigued athletes, and of its reversal following probiotic therapy.

Review of the Diabetes Heart Study (DHS) Family of Studies: A Comprehensively Examined Sample for Genetic and Epidemiological Studies of Type 2 Diabetes and its Complications

The Diabetes Heart Study (DHS) is a genetic and epidemiological study of 1,443 European American and African American participants from 564 families with multiple cases of type 2 diabetes. Initially, participants were comprehensively examined for measures of subclinical cardiovascular disease (CVD) including computed tomography measurement of vascular calcified plaque, ultrasound imaging of carotid artery wall thickness, and electrocardiographic intervals. Subsequent studies have investigated the relationship between bone mineral density and vascular calcification, measures of adiposity, and biomarkers. Ongoing studies are carrying out an extensive evaluation of cerebrovascular disease using magnetic resonance imaging and cognitive assessment. A second, parallel study, the African American DHS, has expanded the sample of African Americans to investigate marked racial differences in subclinical CVD between European Americans and African Americans. Studies in development will evaluate the impact of social stress during the lifecourse on CVD risk, and the prevalence of gastroparesis in this diabetes enriched sample. In addition, the ongoing high mortality rate in DHS participants provides novel insights into the increased risks for type 2 diabetes affected individuals. A comprehensive genetic analysis of the sample is underway using the genome-wide association study (GWAS) approach. Data from this GWAS survey will complement prior family-based linkage data in the analysis of genetic contributors to the wide range of traits in the sample. To our knowledge the DHS family of studies has created the most comprehensively examined sample of individuals with type 2 diabetes yet available, and represents a unique resource for the study people with type 2 diabetes. The aim of this review is to provide a collective overview of the major results from the DHS family of studies, and relate them to the larger body of biomedical investigations of diabetes and its complications.

Coronary Calcium Score and Prediction of All-Cause Mortality in Diabetes: The Diabetes Heart Study

OBJECTIVE In diabetes, it remains unclear whether the coronary artery calcium (CAC) score provides additional information about total mortality risk beyond traditional risk factors. RESEARCH DESIGN AND METHODS A total of 1,051 participants, aged 34–86 years, in the Diabetes Heart Study (DHS) were followed for 7.4 years. Subjects were separated into five groups using baseline computed tomography scans and CAC scores (0–9, 10–99, 100–299, 300–999, and ≥1,000). Logistic regression was performed adjusting for age, sex, race, smoking, and LDL cholesterol to examine the association between CAC and all-cause mortality. Areas under the curve with and without CAC were compared. Natural splines using continuous measures of CAC were fitted to estimate the relationship between observed CAC and mortality risk. RESULTS A total of 17% (178 of 1,051) of participants died during the follow-up. In multivariate analysis, the odds ratios (95% CIs) for all-cause mortality, using CAC 0–9 as the reference group, were CAC 10–99: 1.40 (0.57–3.74); CAC 100–299: 2.87 (1.17–7.77); CAC 300–999: 3.04 (1.32–7.90); and CAC ≥1,000: 6.71 (3.09–16.87). The area under the curve without CAC was 0.68 (95% CI 0.66–0.70), and the area under the curve with CAC was 0.72 (0.70–0.74) (P = 0.0001). Using splines, the estimated risk (95% CI) of mortality for a CAC of 0 was 6.7% (4.6–9.7), and the risk increased nearly linearly, plateauing at CAC ≥1,000 (20.0% [15.7–25.2]). CONCLUSIONS In diabetes, CAC was shown to be an independent predictor of mortality. Participants with CAC (0–9) were at lower risk (0.9% annual mortality). The risk of mortality increased with increasing levels of CAC, plateauing at approximately CAC ≥1,000 (2.7% annual mortality). More research is warranted to determine the potential utility of CAC scans in diabetes.

Coronary Calcium Score Predicts Cardiovascular Mortality in Diabetes Diabetes Heart Study

OBJECTIVE In type 2 diabetes mellitus (T2DM), it remains unclear whether coronary artery calcium (CAC) provides additional information about cardiovascular disease (CVD) mortality beyond the Framingham Risk Score (FRS) factors. RESEARCH DESIGN AND METHODS A total of 1,123 T2DM participants, ages 34–86 years, in the Diabetes Heart Study followed up for an average of 7.4 years were separated using baseline computed tomography scans of CAC (0–9, 10–99, 100–299, 300–999, and ≥1,000). Logistic regression was performed to examine the association between CAC and CVD mortality adjusting for FRS. Areas under the curve (AUC) with and without CAC were compared. Net reclassification improvement (NRI) compared FRS (model 1) versus FRS+CAC (model 2) using 7.4-year CVD mortality risk categories 0% to <7%, 7% to <20%, and ≥20%. RESULTS Overall, 8% of participants died of cardiovascular causes during follow-up. In multivariate analysis, the odds ratios (95% CI) for CVD mortality using CAC 0–9 as the reference group were, CAC 10–99: 2.93 (0.74–19.55); CAC 100–299: 3.17 (0.70–22.22); CAC 300–999: 4.41(1.15–29.00); and CAC ≥1,000: 11.23 (3.24–71.00). AUC (95% CI) without CAC was 0.70 (0.67–0.73), AUC with CAC was 0.75 (0.72–0.78), and NRI was 0.13 (0.07–0.19). CONCLUSIONS In T2DM, CAC predicts CVD mortality and meaningfully reclassifies participants, suggesting clinical utility as a risk stratification tool in a population already at increased CVD risk.

Influence of training loads on patterns of illness in elite distance runners

Objective:To investigate relationships between training mileage and intensity, and the type, incidence, severity, and duration of respiratory illness in distance runners, and the impact of illness on submaximal and maximal running performance. Design:A longitudinal observational study of distance runners with serial monitoring of training loads and clinical patterns of illness. Setting:A 4-month winter training period in the Southern Hemisphere. Participants:A total of 20 highly trained (elite) male middle-distance and distance runners competing at the national and international levels. Main Outcome Measures:Training was quantified by mileage (km), intensity (scale, 1-5), and load (volume × intensity). Symptoms and signs of respiratory illness (type, duration, and severity) were verified by a physician at a weekly review. Performance was monitored by measuring submaximal and maximal oxygen uptake and time to exhaustion on a incremental treadmill test. Results:A majority of subjects (15/20) experienced 1 or more episodes of respiratory illness (mean, 2.5 episodes; range, 1-5), with 79% of symptoms classified as upper respiratory in origin. There were no significant differences in mean weekly mileage (P = 0.43), training intensity (P = 0.85), or training load (P = 0.45) between healthy runners and those affected by illness. Mean weekly (88 ± 46 km) and mean monthly (373 ± 163 km) mileages prior to each episode of illness were similar to the overall study means (95.5 ± 36.4 km and 382 ± 146 km). There were no substantial relationships between mean weekly training mileage, intensity, or training load and the number of illnesses reported (all r < 0.20). Neither submaximal nor maximal running performance was significantly affected by the presence of illness. Conclusions:Differences in training mileage, intensity, and load were not associated with the incidence of respiratory illness in highly trained middle-distance and distance runners. Runners with mild illness can be reassured that symptoms will not necessarily impair submaximal and maximal performance.

Admixture mapping of coronary artery calcified plaque in African Americans with type 2 diabetes mellitus

Background—The presence and severity of coronary artery calcified plaque (CAC) differs markedly between individuals of African and European descent, suggesting that admixture mapping may be informative for identifying genetic variants associated with subclinical cardiovascular disease. Methods and Results—Admixture mapping of CAC was performed in 1040 unrelated African Americans with type 2 diabetes mellitus from the African American-Diabetes Heart Study, Multi-Ethnic Study of Atherosclerosis and Family Heart Study using the Illumina custom ancestry informative marker panel. All cohorts obtained computed tomography scanning of the coronary arteries using identical protocols. For each ancestry informative marker, the probability of inheriting 0, 1, and 2 copies of a European-derived allele was determined. Linkage analysis was performed by testing for association between each ancestry informative marker using these probabilities and CAC, accounting for global ancestry, age, sex, and study. Markers on 1p32.3 in the GLIS1 gene (rs6663966, logarithm of odds [LOD]=3.7), 1q32.1 near CHIT1 (rs7530895, LOD=3.1), 4q21.2 near PRKG2 (rs1212373, LOD=3.0), and 11q25 in the OPCML gene (rs6590705, LOD=3.4) had statistically significant LOD scores, whereas markers on 8q22.2 (rs6994682, LOD=2.7), 9p21.2 (rs439314, LOD=2.7), and 13p32.1 (rs7492028, LOD=2.8) manifested suggestive evidence of linkage. These regions were uniformly characterized by higher levels of European ancestry associating with higher levels or odds of CAC. Findings were replicated in 1350 African Americans without diabetes mellitus and 2497 diabetic European Americans from Multi-Ethnic Study of Atherosclerosis and the Diabetes Heart Study. Conclusions—Fine mapping these regions will likely identify novel genetic variants that contribute to CAC and clarify racial differences in susceptibility to subclinical cardiovascular disease.

Muscle damage, inflammation, and recovery interventions during a 3-day basketball tournament

Abstract Cold water immersion and compression garments are now popular strategies for post-exercise recovery. However, little information exists on the effectiveness of these strategies to minimize muscle damage, or any impact they may have on biomarker clearance after team sport competition. The main aim of this study was to investigate the time course of muscle damage markers and inflammatory cytokines during basketball tournament play. We also wished to examine if cold water immersion and compression recovery strategies ameliorate any post-game increases of these biomarkers, compared with traditional refuelling and stretching routines. Male basketball players (age 19.1 years, s=2.1; height 1.91 m, s=0.09; body mass 87.9 kg, s=15.1) were asked to compete in a three-day tournament playing one game each day. Players were assigned to one of three recovery treatments: carbohydrate+stretching (control, n=9), cold-water immersion at 11°C for 5×1 min (n=10); or full-leg compression at 18 mmHg for ∼18 h (n=10). Players received their treatment after each game on three consecutive days. Venous blood samples were assayed before the tournament and at 10 min, 6 h, and 24 h after each game for concentrations of the muscle damage markers fatty-acid binding protein (FABP), creatine kinase, and myoglobin; interleukin-6 (IL-6) and interleukin-10 (IL-10) were also assayed. Inferences were based on log-transformed concentrations. Post-game increases in damage markers were clear and very large for FABP after the cold water immersion (3.81 ×/÷ 1.19, factor mean ×/÷ factor s), compression (3.93 ×/÷ 1.46), and control (4.04 ×/÷ 1.19) treatments. Increases in myoglobin were also clear and very large after the cold water immersion (3.50 ×/÷ 1.35), compression (3.66 ×/÷ 1.48), and control (4.09 ×/÷ 1.18) treatments. Increases in creatine kinase were clear but small after the cold water immersion (1.30 ×/÷ 1.03), compression (1.25 ×/÷ 1.39), and control (1.42 ×/÷ 1.15) treatments, with small or unclear differences between treatments. There were clear moderate to large post-game increases in IL-6 for cold water immersion (2.75 ×/÷ 1.37), compression (3.43 ×/÷ 1.52), and control (3.47 ×/÷ 1.49). Increases in IL-10 were clear and moderate for cold water immersion (1.75 ×/÷ 1.43), but clear and large after the compression (2.46 ×/÷ 1.79) and control (2.32 ×/÷ 1.41) treatments. Small decreases in IL-6 and IL-10 were observed with cold water immersion compared with the compression and control treatments, with unclear effects between treatments over the tournament. There was no clear benefit from any recovery treatment post-game, as the differences between treatments for all biomarker measures were small or unclear. Pre- to post-tournament increases in FABP, myoglobin, and creatine kinase were clearly small to moderate. There were also small to moderate differences between cold water immersion and the compression (0.85 ×/÷ 1.21) and control (0.76 ×/÷ 1.26) treatments for the post-tournament measures compared with pre-tournament. Pre- to post-tournament changes for IL-6 and IL-10 were unclear, as were the differences between treatments for both cytokines. Tournament basketball play elicits modest elevations of muscle damage markers, suggesting disruption of myocyte membranes in well-trained players. The magnitude of increase in muscle damage markers and inflammatory cytokines post-game ranged from small for creatine kinase, to large for IL-6 and IL-10, to very large for FABP and myoglobin. Cold water immersion had a small to moderate effect in decreasing FABP and myoglobin concentrations after a basketball tournament compared with the compression and control treatments.