E. Bobbioni-Harsch

Lipid peroxidation in skeletal muscle of obese as compared to endurance-trained humans: a case of good vs. bad lipids?

Intra‐myocellular triglycerides (IMTG) accumulate in the muscle of obese and endurance‐trained (ET) humans and are considered a pathogenic factor in the development of insulin resistance, in the former. We postulate that this paradox may be associated with the peroxidation status of the IMTG. IMTG content was the same in the obese and ET subjects. The lipid peroxidation/IMTG ratio was 4.2‐fold higher in the obese subjects. Hence, obesity results in an increased level of IMTG peroxidation while ET has a protective effect on IMTG peroxidation. This suggests a link between the lipid peroxidation/IMTG ratio and insulin resistance.

Open questions about metabolically normal obesity

Subsets of obese subjects without any cardiometabolic risk factors have been repeatedly described. This raises questions whether obesity ‘per se’ enhances the risk for cardiovascular or metabolic diseases and whether healthy obese subjects would benefit from a medical treatment. In order to answer these questions, as a first step, an expert consensus should be reached for the definition of metabolic normality. In fact, up to now, different parameters related to the metabolic syndrome and/or to insulin sensitivity have been utilized across studies. Once an agreement is reached, population-based studies should be undertaken to establish the incidence of metabolic normality among obese subjects. Furthermore, many other parameters such as age, sex, race, fat distribution and physical activity should be monitored to obtain results representative of a general population. Longitudinal studies aimed at investigating the evolution of the cardiometabolic profile of healthy obese subjects are also needed. In conclusion, data from the literature strongly suggest that a regular surveillance of the cardiometabolic parameters and a prevention of any further weight gain should be applied to healthy obese individuals, whereas possible benefits of a weight loss treatment are still a matter of debate.

Uncoupling protein-3 expression in skeletal muscle and free fatty acids in obesity

The newly identified mitochondrial uncoupling proteins UCP2 and UCP3, by contrast with UCP1, are highly expressed in human beings, UCP2 being ubiquitous and UCP3 specific to skeletal muscle. Because of its tissue distribution, UCP3 might have an important role in wholebody energy homoeostasis in human beings. Variations in its degree of expression might contribute to the interindividual variability in resting energy expenditure and in the energybalance dysregulation found in obesity and type 2 diabetes. We investigated whether mRNA expression of UCP2 and UCP3 in human vastus lateralis muscle was correlated with variables related to fat or glucose metabolism and with resting energy expenditure in a mixed population of obese patients and obese patients with type 2 diabetes. Nine obese, 10 h fasted patients, including three with type 2 diabetes (untreated but dietetically controlled, fasting plasma glucose of 8·1 to 10·5 mmol/L, table), volunteered, with written consent, to participate, which was accepted by the local Human Investigation Committee. We measured lean body mass with bioelectrical impedance. Plasma glucose concentrations were determined with a Beckman Glucose Analyzer II (Beckman Instruments, CA, USA), and plasma free fatty acids and insulin concentrations with commercial kits (Wako Chemicals GmbH, Germany, and Abbott, IL). Glucose uptake was measured with a euglycaemic hyperinsulinaemic clamp, and glucose and lipid oxidation rates, as well as resting energy expenditure, were determined by indirect calorimetry. The concentrations of UCP2 and UCP3 mRNA in vastus lateralis biopsy fragments were measured by northern blot. The expression of UCP2 and UCP3 mRNA normalised to the respective concentrations of 18S rRNA were compared with 12 physical, biological, and metabolic variables and analysed (Simple Pearson ProductMoment correlations). The mRNA expression of UCP3 was positively and linearly correlated with circulating free fatty acids (r=0·83; p=0·005), whereas that of UCP2 was not (r=0·40). When adjustments were made for age, percentage of fat mass, body-mass index, lean body mass and bodyweight, the correlation between UCP3 mRNA and concentrations of free fatty acids was stronger (r=0·99; p 0·05) was seen between UCP2 or UCP3 mRNA expression and age, percentage fat mass, body-mass index, lean body mass, resting energy expenditure per kg lean body mass, bodyweight, fasting plasma glucose, insulin concentrations, insulin-induced glucose uptake, glucose oxidation, and lipid oxidation. Free fatty acids might control muscle UCP3 expression. A 10-day severe calorie restriction increases muscle UCP2 and UCP3 mRNA expression, and in rodents infusion of free fatty acids increases muscle UCP3 mRNA. Our data suggest a role for muscle UCP3 in the metabolic adaptations to increases in fatty-acid supply, and, therefore, the involvement of UCP3 in a compensatory mechanism linking obesity to increased muscle thermogenesis.

Factors influencing energy intake and body weight loss after gastric bypass.

Objective: The gastric bypass-induced quantitative and qualitative modifications of energy intake (En In, kcal/day) and their impact on body weight (bw) loss were evaluated. The factors influencing energy intake and body weight loss were also investigated.Design: Longitudinal study.Setting: University Hospital of Geneva.Subjects: Fifty obese women undergoing a Roux-en-Y gastric bypass.Results: The reduction of EnIn was significantly related to bw loss expressed either in kg or as percentage correction of excess bw (P<0.01 for both), whereas the post-operative modifications of diet composition did not play a role. Age and initial bw significantly influenced bw loss (P<0.0001 and P<0.001, respectively), as shown by multiple regression analysis. Patients were divided into four sub-groups according to their age (under or over 35 y) and initial bw (under or over 120 kg). ANOVA showed that under 35-y-old subjects reduced their EnIn significantly more than their older counterparts having similar bw (P<0.02 and P<0.05); consequently, bw loss, expressed in kg, was significantly (P<0.0001 and P<0.0005) larger in younger patients. Subjects with an initial bw over 120 kg lost significantly (P<0.001 and P<0.02) more weight as compared to patients with a smaller degree of obesity (under 120 kg) and similar age.Conclusions: Gastric bypass-induced body weight loss is mainly due to the reduction of EnIn, whereas the qualitative modifications of the diet do not play a role. Younger subjects have a greater capacity to reduce EnIn and, therefore, lose more weight. Pre-operative high degree of obesity leads to a larger weight reduction, probably because of a greater energy deficit.

Impact of body fat mass extent on cardiac autonomic alterations in women

Background  Obesity has been associated with significant abnormalities of the cardiac autonomic regulation. However, the precise impact of increasing body weight on cardiac autonomic function and the metabolic and hormonal contributors to these changes are presently unclear. The aim of our study was to explore in subjects with increasing values of body mass index (BMI) the alterations of cardiac autonomic function and to establish the potential role of various metabolic and hormonal contributors to these alterations.

From Metabolic Normality to Cardiometabolic Risk Factors in Subjects With Obesity

The aim of the study was to evaluate the 3 years incidence of cardiometabolic risk factors, such as impaired fasting glucose, reduced high‐density lipoprotein (HDL)‐cholesterol, increased plasma triglycerides or blood pressure as well as impaired glucose tolerance in overweight or obese (ow/ob) and normal body weight (nbw) subjects metabolically normal at baseline. Subjects from the Relationship between Insulin Sensitivity and Cardiovascular Disease (RISC) study were analyzed. We analyzed 284 nbw and 152 ow/ob subjects who, at baseline, did not show any of the above‐mentioned cardiometabolic risk factors. At 3 years, these parameters were re‐evaluated. Intima‐media thickness (IMT) of the common carotid artery (CCA) was echographically measured. At follow‐up, the incidence of one or more cardiometabolic risk factors was 57.2% in ow/ob vs. 31.7% in nbw (P < 0.0001). After adjustment for age, sex, menopause status, lifestyle parameters, insulin sensitivity, and fasting insulinemia, BMI remained significantly linked to the development of one or more cardiometabolic risk factors (P = 0.02). An increased BMI at follow‐up was significantly associated with the development of cardiometabolic alterations, in both nbw and ow/ob groups (P = 0.04). Ow/ob subjects who, at 3 years follow‐up, remained metabolically normal, showed a less favourable cardiometabolic profile, when compared to nbw counterparts. In ow/ob metabolically normal males and females, intima‐media of the common carotid at follow‐up was thicker than in nbw (P = 0.03 for males, P = 0.04 for females). In conclusion, metabolically normal obese subjects show a higher incidence of cardiometabolic risk factors, in a short follow‐up period. Weight gain is significantly associated with the development of these factors, in both nbw and ow/ob subjects.

Metabolic normality in overweight and obese subjects. Which parameters? Which risks?

Objectives:The objective of this study was to define metabolic normality and to investigate the cardiometabolic profile of metabolically normal obese.Design:Cross-sectional study conducted at 21 research centers in Europe.Subjects:Normal body weight (nbw, n=382) and overweight or obese (ow/ob, n=185) subjects free from metabolic syndrome and with normal glucose tolerance, were selected among the Relationship between Insulin Sensitivity and Cardiovascular Disease study participants.Main outcome measures:Insulin sensitivity was assessed by the clamp technique. On the basis of quartiles in nbw subjects, the limits of normal insulin sensitivity and of normal fasting insulinemia were established. Subjects with normal insulin sensitivity and fasting insulin were defined as metabolically normal.Results:Among ow/ob subjects, 11% were metabolically normal vs 37% among nbw, P<0.0001. Ow/ob subjects showed increased fasting insulin (P=0.0009), low-density lipoprotein cholesterol (LDL-cholesterol) (P=0.004), systolic (P=0.0007) and diastolic (P=0.001) blood pressure, as compared with nbw. When evaluating the contribution of body mass index (BMI), hyperinsulinemia and insulin resistance, BMI showed an isolated effect on high-density lipoprotein (P=0.007), high-sensitivity C-reactive protein (P<0.0001), systolic (P=0.002) and diastolic (P=0.008) blood pressures. BMI shared its influence with insulinemia on total cholesterol (P=0.04 and 0.003, respectively), LDL-cholesterol (P=0.003 and 0.006, respectively) and triglycerides (P=0.02 and 0.001, respectively).Conclusion:In obese subjects, fasting insulin should be taken into account in the definition of metabolic normality. Even when metabolically normal, obese subjects could be at increased risk for cardiometabolic diseases. Increased BMI, alone or with fasting insulin, is the major responsible for the less favorable cardio-metabolic profile.

Energy expenditure and substrates oxidative patterns, after glucose, fat or mixed load in normal weight subjects.

Objectives: To evaluate energy balance after three isocaloric oral loads of different composition and to establish possible relationships between the substrates oxidative patterns and the modifications of insulin and free fatty acids (FFA) plasma profiles. Design: Each subject received, in a randomized order, three oral loads of 2658±45 kJ (636±11 Kcal) either as glucose, lipids (cream) or a mixture (glucose+cream). Setting: The experiments were performed at the University Hospital of Geneva. Subjects: Ten normal body-weight volunteers. Methods: Energy expenditure (EE) and substrates oxidation were measured by indirect calorimetry during 8 h following each load. Plasma glucose, insulin and FFA were also measured. Results: EE was 1776±107, 1818±125 and 1785±117 KJ over 8 h after glucose, mixed and lipids load, respectively. Glucose oxidation was the highest after oral glucose as compared to mixed and lipids load, while the highest value of lipids oxidation was measured after fat load. A significant relationship linked fat oxidation to plasma FFA (r=0.54, P<0.002) as well as to insulin (r=−0.40, P<0.002). Conclusions: (a) The energetic cost of glucose and fat intake is the same; (2) after each load, the main source of energy corresponds to the substrate administered; (3) both plasma insulin and FFA influence the substrate oxidative patterns observed after each load; (4) alimentary fat may contribute to fat oxidation by maintaining elevated plasma FFA levels.

Relationship between sympathetic reactivity and body weight loss in morbidly obese subjects

OBJECTIVE: To investigate the possible role of peripheral sympathetic activity in gastric bypass-induced body weight loss.SUBJECTS AND METHODS: In 42 morbidly obese patients (sex: 36 f/6 m; BMI: 46.0±0.7 kg/m2) undergoing a gastric bypass, the skin vasoconstrictor reflex in answer to a deep inspiration was measured by laser Doppler fluximetry. The extent of vasoconstriction, measured at the second finger of the left hand, was expressed as percent reduction of the basal blood flux (% vasoconstriction). Insulin sensitivity was assessed before surgery in a subset of patients (n=11), by the method of euglycemic, hyperinsulinemic clamp. Body weight and composition were evaluated before, and 3, 6 and 12 months after surgery. At the same time points, energy intake (kJ/day) was evaluated by means of both food record diary and alimentary anamnesis.RESULTS: The % vasoconstriction, which was significantly (P=0.01) greater in normoglycemic subjects than in diabetic ones, was also significantly (P=0.03) related to the extent of insulin sensitivity measured during the euglycemic clamp.The % vasoconstriction showed a significant (P>0.0001), positive correlation with weight reduction obtained between the 6th and 12th months following surgery; as a consequence, % vasoconstriction was significantly (P=0.0004) related to the overall body weight loss achieved during the year following the operation. These correlations remained significant in multiple regression analysis with adjustment for age, initial body weight, plasma glucose and insulin (P=0.0007 and 0.006, respectively). The % vasoconstriction was also significantly (P=0.0006), negatively related to energy intake measured 12 months after surgery.CONCLUSIONS: In conditions of stable body weight, the sympathetic nervous system (SNS) reactivity is influenced by the degree of insulin resistance. A high capacity to activate the SNS, measured before surgery, is associated with both a larger gastric bypass-induced weight loss and a lower energy intake, at the phase of weight stabilization.

Independent Evolution of Heart Autonomic Function and Insulin Sensitivity During Weight Loss

In order to investigate the improvement of insulin resistance and cardiac autonomic function along massive weight loss, 12 obese women were evaluated before, and 3 and 12 months after Roux‐en‐Y gastric bypass. The 12‐month values were compared to those of BMI‐matched controls. Insulin sensitivity was assessed by euglycemic clamp and the cardiac autonomic function by the analysis of the Heart Rate Variability (HRV). After surgery, glucose uptake progressively increased from 4.3 ± 0.5 mg/kg lean body mass (LBM)/min preoperative (pre‐op) to 4.9 ± 0.5 and 7.0 ± 0.5, 3‐ and 12‐month postoperative (post‐op) (P = 0.04 and P = 0.006 vs. pre‐op), whereas the cardiac autonomic function showed a biphasic pattern. HRV values increased 3 months post‐op, and decreased at 12 months, thus indicating an early sympathetic withdrawal followed by a later reactivation (e.g., the standard deviation of the normal‐to‐normal intervals was 116 ± 7 ms in pre‐op, 161 ± 10 at 3 months, P = 0.008 vs. pre‐op, and 146 ± 15 at 12 months, P = 0.03 vs. pre‐op and P = 0.02 vs. 3 m). Insulin sensitivity was significantly related to body weight (P = 0.02), whereas the cardiac indexes were significantly linked to the profile of energy intake (e.g., HRV triangular index vs. energy intake P = 0.003). No significant relationship linked insulin sensitivity to the cardiac autonomic indexes. Insulin sensitivity and cardiac parameters of the 12‐month post‐op patients were similar to their matched controls. During massive weight loss, the cardiac autonomic deregulation and insulin resistance improved concomitantly but independently from each other. Our results suggest that the extent of the improvement is associated with the final body weight.