I. Sadaf Farooqi

Beneficial effects of leptin on obesity, T cell hyporesponsiveness, and neuroendocrine/metabolic dysfunction of human congenital leptin deficiency

The wide range of phenotypic abnormalities seen in the leptin-deficient ob/ob mouse and their reversibility by leptin administration provide compelling evidence for the existence of multiple physiological functions of this hormone in rodents. In contrast, information regarding the roles of this hormone in humans is limited. Three morbidly obese children, who were congenitally deficient in leptin, were treated with daily subcutaneous injections of recombinant human leptin for up to 4 years with sustained, beneficial effects on appetite, fat mass, hyperinsulinemia, and hyperlipidemia. Leptin therapy resulted in a rapid and sustained increase in plasma thyroid hormone levels and, through its age-dependent effects on gonadotropin secretion, facilitated appropriately timed pubertal development. Leptin deficiency was associated with reduced numbers of circulating CD4(+) T cells and impaired T cell proliferation and cytokine release, all of which were reversed by recombinant human leptin administration. The subcutaneous administration of recombinant human leptin has major and sustained beneficial effects on the multiple phenotypic abnormalities associated with congenital human leptin deficiency.

The Obesity-Associated FTO Gene Encodes a 2-Oxoglutarate–Dependent Nucleic Acid Demethylase

Variants in the FTO (fat mass and obesity associated) gene are associated with increased body mass index in humans. Here, we show by bioinformatics analysis that FTO shares sequence motifs with Fe(II)- and 2-oxoglutarate–dependent oxygenases. We find that recombinant murine Fto catalyzes the Fe(II)- and 2OG-dependent demethylation of 3-methylthymine in single-stranded DNA, with concomitant production of succinate, formaldehyde, and carbon dioxide. Consistent with a potential role in nucleic acid demethylation, Fto localizes to the nucleus in transfected cells. Studies of wild-type mice indicate that Fto messenger RNA (mRNA) is most abundant in the brain, particularly in hypothalamic nuclei governing energy balance, and that Fto mRNA levels in the arcuate nucleus are regulated by feeding and fasting. Studies can now be directed toward determining the physiologically relevant FTO substrate and how nucleic acid methylation status is linked to increased fat mass.

A frameshift mutation in MC4R associated with dominantly inherited human obesity

T he melanocortin-4 receptor (MC4R) is a G-protein coupled, seven-trans-membrane receptor which is highly expressed in the hypothalamus, a region of the brain intimately involved in appetite regulation 1. It is a high-affinity receptor for αMSH, a product of the pro-opiomelanocortin (POMC) gene, which inhibits feeding when administered to rodents 2. Hypothalamic POMC neurons are stimulated by leptin, an adipocyte-specific hormone which regulates appetite and energy expenditure, and constitute a link between leptin and the melanocortin system. Mc4r-deficient mice are hyper-phagic, severely obese, hyperinsulinaemic and show increased linear growth 3. Mice heterozygous for a null Mc4r allele exhibit weight gain intermediate to that seen in wild-type and homozygous mutant litter-mates. Additionally, ectopic expression in the brain of agouti 4 and agouti-related transcript 5 , natural antagonists of the MC4R ligand, αMSH, results in obesity in rodents. In humans, obesity syndromes associated with abnormalities in POMC (ref. 6) and prohormone processing defects involving POMC (ref. 7) have also been described. We have identified a cohort of severely obese children in whom no evidence for a recognized clinical syndrome or a structural hypothalamic cause for their obesity has been found. All are severely obese (mean body mass index (weight/height 2) is 34 kg/m 2) from an early age (<10 years). Sixty-three of these subjects were screened for mutations in MC4R by direct nucleotide sequencing. We identified one subject who was heterozygous for a 4-bp deletion at codon 211 (Fig. 1b). This results in a frameshift that introduces five aberrant amino acids culminating in a stop codon in the region encoding the fifth transmembrane domain, resulting in a truncated protein. As residues at the base of the fifth and sixth transmembrane domains are needed for G-protein binding and activation 8 , this mutation is likely to result in a non-functional receptor. No mutations were found in the 62 other subjects studied. The index patient II.1 (Fig. 1a) is four years old and is the only child from a non-consanguinous union. His weight is 32 kg (>99th centile), height 107 cm (91st cen-tile) and body mass index (BMI) is 28 kg/m 2 (>99th centile). His birthweight was 3.8 kg (50th centile), and progressive weight gain was noted from the age of four months (Fig. 2a). There is no clinical or biochemical evidence of adrenal or thyroid disease, the subject has a normal karyotype and intellectual development is normal. There is a history of hyperphagia …

Dominant and recessive inheritance of morbid obesity associated with melanocortin 4 receptor deficiency

Over 20 severely obese subjects in 11 independent kindreds have been reported to have pathogenic heterozygous mutations in the gene encoding the melanocortin 4 receptor (MC4R), making this the most common known monogenic cause of human obesity. To date, the detailed clinical phenotype of this dominantly inherited disorder has not been defined, and no homozygous subjects have been described. We determined the nucleotide sequence of the entire coding region of the MC4R gene in 243 subjects with severe, early-onset obesity. A novel two-base pair GT insertion in codon 279 was found in two unrelated subjects, and four novel missense mutations, N62S, R165Q, V253I, C271Y, and one mutation (T112M) reported previously were found in five subjects. N62S was found in homozygous form in five children with severe obesity from a consanguineous pedigree. All four heterozygous carriers were nonobese. Several features of the phenotype, e.g. hyperphagia, tendency toward tall stature, hyperinsulinemia, and preserved reproductive function, closely resemble those reported previously in Mc4r knock-out mice. In addition, a marked increase in bone mineral density was seen in all affected subjects. In transient transfection assays, the N62S mutant receptor showed a responsiveness to alphaMSH that was intermediate between the wild-type receptor and mutant receptors carrying nonsense and missense mutations associated with dominantly inherited obesity. Thus MC4R mutations result in a syndrome of hyperphagic obesity in humans that can present with either dominant or recessive patterns of inheritance.

The Hormonal Control of Food Intake

Numerous circulating peptides and steroids produced in the body influence appetite through their actions on the hypothalamus, the brain stem, and the autonomic nervous system. These hormones come from three major sites—fat cells, the gastrointestinal tract, and the pancreas. In this Review we provide a synthesis of recent evidence concerning the actions of these hormones on food intake.

Leptin Regulates Striatal Regions and Human Eating Behavior

Studies of the fat-derived hormone leptin have provided key insights into the molecular and neural components of feeding behavior and body weight regulation. An important challenge lies in understanding how the rewarding properties of food interact with, and can override, physiological satiety signals and promote overeating. We used functional magnetic resonance imaging to measure brain responses in two human patients with congenital leptin deficiency who were shown images of food before and after 7 days of leptin replacement therapy. Leptin was found to modulate neural activation in key striatal regions, suggesting that the hormone acts on neural circuits governing food intake to diminish the perception of food reward while enhancing the response to satiety signals generated during food consumption.

Large, rare chromosomal deletions associated with severe early-onset obesity

Obesity is a highly heritable and genetically heterogeneous disorder. Here we investigated the contribution of copy number variation to obesity in 300 Caucasian patients with severe early-onset obesity, 143 of whom also had developmental delay. Large (>500 kilobases), rare (<1%) deletions were significantly enriched in patients compared to 7,366 controls (P < 0.001). We identified several rare copy number variants that were recurrent in patients but absent or at much lower prevalence in controls. We identified five patients with overlapping deletions on chromosome 16p11.2 that were found in 2 out of 7,366 controls (P < 5 × 10-5). In three patients the deletion co-segregated with severe obesity. Two patients harboured a larger de novo 16p11.2 deletion, extending through a 593-kilobase region previously associated with autism and mental retardation; both of these patients had mild developmental delay in addition to severe obesity. In an independent sample of 1,062 patients with severe obesity alone, the smaller 16p11.2 deletion was found in an additional two patients. All 16p11.2 deletions encompass several genes but include SH2B1, which is known to be involved in leptin and insulin signalling. Deletion carriers exhibited hyperphagia and severe insulin resistance disproportionate for the degree of obesity. We show that copy number variation contributes significantly to the genetic architecture of human obesity.

Obesity associated genetic variation in FTO is associated with diminished satiety.

CONTEXT Polymorphisms within the FTO gene have consistently been associated with obesity across multiple populations. However, to date, it is not known whether the association between genetic variation in FTO and obesity is mediated through effects on energy intake or energy expenditure. OBJECTIVE Our objective was to examine the association between alleles of FTO known to increase obesity risk and measures of habitual appetitive behavior. METHODS The intronic FTO single nucleotide polymorphism (rs9939609) was genotyped in 3337 United Kingdom children in whom measures of habitual appetitive behavior had been assessed using two scales (Satiety Responsiveness and Enjoyment of Food) from the Child Eating Behaviour Questionnaire, a psychometric tool that has been validated against objective measures of food intake. Associations of FTO genotype with indices of adiposity and appetite were assessed by ANOVA. RESULTS As expected, the A allele was associated with increased adiposity in this cohort and in an independent case-control replication study of United Kingdom children of similar age. AA homozygotes had significantly reduced Satiety Responsiveness scores (P = 0.008, ANOVA). Mediation analysis indicated that the association of the AA genotype with increased adiposity was explained in part through effects on Satiety Responsiveness. CONCLUSIONS We have used a unique dataset to examine the relationship between a validated measure of childrens habitual appetitive behavior and FTO obesity risk genotype and conclude that the commonest known risk allele for obesity is likely to exert at least some of its effects by influencing appetite.

A de novo mutation affecting human TrkB associated with severe obesity and developmental delay

An 8-year-old male with a complex developmental syndrome and severe obesity was heterozygous for a de novo missense mutation resulting in a Y722C substitution in the neurotrophin receptor TrkB. This mutation markedly impaired receptor autophosphorylation and signaling to MAP kinase. Mutation of NTRK2, which encodes TrkB, seems to result in a unique human syndrome of hyperphagic obesity. The associated impairment in memory, learning and nociception seen in the proband reflects the crucial role of TrkB in the human nervous system.

Early childhood infection and atopic disorder

BACKGROUND Atopy is of complex origins but the recent rise in atopic diseases in westernised communities points to the action of important environmental effects. One candidate mechanism is the changing pattern of microbial exposure in childhood. This epidemiological study investigated the relationship between childhood infections and subsequent atopic disease, taking into account a range of social and medical variables. METHODS A total of 1934 subjects representing a retrospective 1975–84 birth group at a family doctor practice in Oxfordshire were studied. Public health and practice records were reviewed; temporal records were made of all diagnoses of infections and their treatments, all immunisations, and diagnoses of asthma, hay fever and eczema; maternal atopy and a number of other variables were documented. RESULTS Logistic regression analysis identified three statistically significant predictors of subsequent atopic disease: maternal atopy (1.97, 95% CI 1.46 to 2.66, p<0.0001), immunisation with whole-cell pertussis vaccine (1.76, 95% CI 1.39 to 2.23, p<0.0001), and treatment with oral antibiotics in the first two years of life (2.07, 95% CI 1.64 to 2.60, p<0.0001). There was no significant association found for maternal smoking, bottle feeding, sibship size, or social class. CONCLUSIONS The prediction of atopic disease by maternal atopy mainly reflects the effect of acknowledged genetic factors. Interpretation of the prediction of atopic disorders by immunisation with whole-cell pertussis vaccine and treatment with oral antibiotics needs to be very cautious because of the possibilities of confounding effects and reverse causation. However, plausible immune mechanisms are identifiable for the promotion of atopic disorders by both factors and further investigation of these associations is warranted.