Irene M. Conwell

Prospective Study of Gut Hormone and Metabolic Changes After Adjustable Gastric Banding and Roux-en-Y Gastric Bypass

Objective:The objective of this study was to quantify hormones that regulate energy and glucose homeostasis to establish possible mechanisms for the greater efficacy of Roux-en-Y gastric bypass (RYGB) compared with laparoscopic adjustable gastric banding (LAGB) in achieving weight loss and improved insulin sensitivity.Design:Longitudinal study of patients undergoing LAGB (n=15) and RYGB (n=28) who were studied before surgery and at 2, 12, 26 and 52 weeks afterwards.Measurements:Fasting blood samples were drawn at each visit. Postprandial blood samples were also obtained before surgery and at 26 and 52 weeks. Samples were assayed for peptide YY (PYY), ghrelin, glucagon-like peptide-1 (GLP-1), glucose, insulin, leptin, thyrotropic hormone, free T4 and free T3.Results:At 1 year there was greater weight loss in RYGB compared with LAGB patients (30 vs 15%), but final body mass index was similar (34 vs 33 kg m−2). At week 52, area under the curve (AUC) for PYY in RYGB subjects was greater than LAGB (P<0.01). GLP-1 levels at 30 min after meal were threefold greater after RYGB compared with LAGB (P<0.001). Conversely, ghrelin AUC increased after LAGB at week 52 (P<0.05) but tended to decrease after RYGB. Fasting glucose, insulin, and leptin and homeostasis model of assessment (HOMA-IR) decreased in both groups over time but were significantly lower at week 52 after RYGB compared with LAGB. The change in leptin correlated significantly with weight loss in LAGB (r=0.86) and RYGB (r=0.77), however, HOMA-IR correlated significantly with weight loss only in LAGB (r=0.78), and not RYGB (r=0.15). There was a significant decrease in free T3 (P<0.01) after RYGB.Conclusions:Differences in levels of gut hormones may play a role in promoting greater weight loss and insulin sensitivity after RYGB compared with LAGB, however, weight loss may be limited by decreases in free T3 and leptin.

Differential Effects of Gastric Bypass and Banding on Circulating Gut Hormone and Leptin Levels

Objective: To quantify plasma concentrations of hormones that regulate energy homeostasis in order to establish possible mechanisms for greater weight loss after Roux‐en‐Y gastric bypass (RYGBP) compared with gastric banding (BND).

Very Low–Calorie Diet Mimics the Early Beneficial Effect of Roux-en-Y Gastric Bypass on Insulin Sensitivity and β-Cell Function in Type 2 Diabetic Patients

Marked improvement in glycemic control occurs in patients with type 2 diabetes mellitus shortly after Roux-en-Y gastric bypass surgery (RYGB) and before there is major weight loss. The objective of this study was to determine whether the magnitude of this change is primarily due to caloric restriction or is unique to the surgical procedure. We studied eleven subjects who underwent RYGB and fourteen subjects mean-matched for BMI, HbA1c, and diabetes duration who were admitted to our inpatient research unit and given a very low–calorie diet (VLCD) of 500 kcal/day with a macronutrient content similar to that consumed by patients after RYGB. Frequently sampled intravenous glucose tolerance tests were performed before and after interventions. Both groups lost an equivalent amount of weight over a mean study period of 21 days. Insulin sensitivity, acute insulin secretion after intravenous glucose administration, and β-cell function as determined by disposition index improved to a similar extent in both groups. Likewise, changes in fasting glucose and fructosamine levels were similar. Based on these data, VLCD improves insulin sensitivity and β-cell function just as well as RYGB in the short term.

Effects of adrenalectomy on AGRP, POMC, NPY and CART gene expression in the basal hypothalamus of fed and fasted rats.

Glucocorticoids regulate body energy balance through both peripheral and central mechanisms. In order to understand the central mechanisms that mediate these effects of glucocorticoids we studied the effects of adrenalectomy (ADX) and food deprivation on the expression of four neuropeptide genes (measured by S1 nuclease protection assay) in the medial basal hypothalamus (MBH), which are known to regulate energy balance: pro-opiomelanocortin (POMC), agouti-related peptide (AGRP), neuropeptide Y (NPY), and cocaine and amphetamine regulated transcript (CART). Adult male rats were ADX or sham operated (SHAM), and studied 1-2 weeks later. In the first study effects of ADX and corticosterone replacement on POMC and AGRP expression were determined. ADX decreased POMC and AGRP gene expression in the MBH by 27 and 38%, respectively, compared to SHAM rats. Corticosterone treatment increased the expression of POMC by 87% and AGRP by 45% in ADX rats. The second study was designed to determine if glucocorticoids are necessary for the fasting induced changes in POMC, AGRP, NPY and CART in the MBH. ADX caused a 20-30% decrease in the expression of all four neuropeptide genes in the MBH. As expected, fasting suppressed POMC and CART expression and increased AGRP and NPY expression. The fasting-induced increases in AGRP and NPY persisted after ADX but no further significant decreases in POMC or CART were noted after fasting in ADX rats. Plasma leptin and insulin declined significantly after ADX and increased with corticosterone replacement; both leptin and insulin declined further in fasted, ADX animals. In conclusion, ADX decreases both anorexigenic, POMC and CART, and orexigenic, AGRP and NPY, neuropeptide gene expression in the MBH. AGRP and NPY decrease after ADX despite the fall in plasma leptin and insulin concentrations which in other situations would increase these neuropeptides. Furthermore, glucocorticoids are not required for fasting-induced upregulation of AGRP and NPY expression.

Concentrations of corticotrophin-releasing hormone in the umbilical-cord blood of pregnancies complicated by pre-eclampsia

The effect of pre-eclampsia on concentrations of corticotrophin releasing hormone (CRH) in umbilical-cord blood of fetuses at delivery was studied in order to determine if fetal CRH is elevated in this disorder when compared with uncomplicated pregnancy. Placental CRH may be a regulator of fetal pituitary-adrenal function and we therefore also measured ACTH, cortisol and dehydroepiandrosterone sulfate (DHEAS) in the umbilical-cord blood. The mean umbilical-cord plasma CRH in the fetuses from pregnancies complicated by pre-eclampsia, 667 +/- 153 pg mL-1, was significantly higher than the plasma CRH in the fetuses from normotensive pregnancies, 185 +/- 22 pg mL-1 (P < 0.001). The mean fetal cortisol concentration was significantly higher in pre-eclampsia, than in the normotensive, pregnancies (pre-eclampsia, 13.5 +/- 1.8; normotensive, 7.6 +/- 1.3 micrograms dL-1; P < 0.001). Plasma DHEAS was 217 +/- 23 micrograms dL-1 in the umbilical-cord blood of the fetuses from pregnancies complicated by pre-eclampsia and 281 +/- 35 micrograms dL-1 in the normotensive pregnancies (P < 0.01). Placental CRH synthesis and release, in contrast to hypothalamic CRH, appears to be stimulated by glucocorticoids. In pregnancies complicated by uteroplacental insufficiency, as may occur in pre-eclampsia, placental CRH production may be enhanced by increased fetal glucocorticoids. In turn, placental CRH may modulate fetal pituitary-adrenal steroidogenesis to favour increased cortisol secretion. Thus, placental CRH may play an important role in the fetal response to a compromised intrauterine environment.

Placental Corticotropin-Releasing Hormone and Pituitary-Adrenal Function during Pregnancy

The placenta secretes large amounts of the hypothalamic releasing hormone, corticotropin-releasing hormone (CRH), into both the maternal and fetal circulation during pregnancy. We characterized the relationship between maternal plasma CRH and products of the pituitary and adrenal in order to investigate the physiologic role of placental CRH in modulating maternal pituitary-adrenal function. Plasma was obtained from 8 women at biweekly intervals between 21 and 40 weeks of full-term pregnancy for CRH, adrenocorticotropin (ACTH), alpha-melanocyte-stimulating hormone (alpha MSH), cortisol, and dehydroepiandrosterone sulfate (DHEAS) measurements by radioimmunoassay. Eighteen women were also studied once at 22-34 weeks of pregnancy with plasma CRH and 24-hour urinary free cortisol measurement. Eight nonpregnant women served as control subjects. Plasma CRH was undetectable in the nonpregnant subjects and rose over the time period studied in the pregnant women. Concentrations of afternoon ACTH and cortisol also rose during pregnancy while DHEAS levels declined in the pregnant women. The alpha-MSH levels were beneath the level of detection (< 20 pg/ml) in both the pregnant and nonpregnant subjects. The overall mean afternoon ACTH concentration was higher in the pregnant than in the nonpregnant women (11.4 +/- 1.8 vs. 5.9 +/- 1.8 pg/ml; p < 0.05), although the ACTH levels in both groups remained within the normal range. The mean plasma cortisol concentrations were higher in the pregnant women, while the mean DHEAS levels were lower in the pregnant women when compared to the nonpregnant subjects.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of fasting, leptin, and insulin on AGRP and POMC peptide release in the hypothalamus

Agouti-related protein (AGRP) and proopiomelanocortin (POMC) have opposing effects on melanocortin receptor (MC-R) signaling and energy balance, and are important targets for leptin and insulin in the hypothalamus. While food intake and leptin have documented effects on POMC and AGRP gene expression, and insulin has effects on POMC gene expression, little is known about their effects on POMC or AGRP peptide release. Here we have examined the effects of fasting, leptin, and insulin on the release of AGRP and the POMC-derived peptide gamma(3)-MSH from the perifused rat hypothalamus in vitro. In the first experiment, fasting (48 h) resulted in a significant overall decrease in gamma(3)-MSH release measured every 20 min during a 3-h baseline perifusion period and after depolarization with 56 mM KCl (p = 0.02); there was a trend towards an overall increase in the release of AGRP but this was not significant. When the ratio of gamma(3)-MSH/AGRP release was calculated at each time point, there was an overall decrease in gamma(3)-MSH/AGRP with fasting (p < 0.01). Further examination of the ratio of gamma(3)-MSH/AGRP revealed a 34% reduction (p < 0.05) in the basal area under the curve (AUC) and a 33% reduction (p < 0.01) in the post-KCl stimulated AUC in fasted vs. fed animals. In the second experiment, perifusion of hypothalamic slices with 10(-8) or 10(-7) M leptin for 2 h resulted in a significant decrease in the release of AGRP noted primarily after depolarization with KCl (p < 0.01); no effect was seen on gamma(3)-MSH release. Similarly, in a third experiment, perifusion with 10(-7) M insulin caused a significant decrease in AGRP release (p < 0.001) without affecting gamma(3)-MSH release. Thus, there is a significant decrease in gamma(3)-MSH and the ratio of gamma(3)-MSH to AGRP released during fasting, consistent with a net inhibition of hypothalamic MC-R signaling. In contrast, short-term treatment with leptin and insulin may inhibit MC-R signaling primarily by decreasing the release of AGRP.

Glucocorticoid Regulation of Hypothalamic Proopiomelanocortin

Although glucocorticoids clearly inhibit proopiomelanocortin (POMC) gene transcription and peptide synthesis in the anterior pituitary, the effects of glucocorticoids on POMC in the hypothalamus are still unclear, even though most POMC neurons in the arcuate nucleus are known to have glucocorticoid receptors. In this study, we have therefore examined the effect of adrenalectomy (ADX) and glucocorticoid replacement on POMC mRNA and peptide (β-EP and α-MSH) levels in the medial basal hypothalamus (MBH) of the rat. POMC mRNA was measured by a sensitive solution hybridization S1 nuclease protection assay, and β-EP and α-MSH were measured by radioimmunoassay. In a first experiment, animals were studied 7 days after ADX or sham surgery. The mean POMC mRNA concentration was 1.01 ± 0.14 pg/µg RNA (means ± SE) in the intact animals and decreased to 0.55 ± 0.07 pg/µg RNA in the MBH of the ADX animals (p < 0.005). β-EP levels decreased in parallel from 4.30 ± 0.18 to 3.36 ± 0.11 ng/mg protein (p < 0.001); α-MSH levels decreased from 3.25 ± 0.21 to 2.41 ± 0.16 ng/mg protein (p < 0.005). In a second experiment, animals were studied 2 weeks after ADX. POMC mRNA levels again fell significantly from 1.15 ± 0.19 pg/µg RNA in the intact animals to 0.51 ± 0.06 pg/µg in the ADX animals (p < 0.01). β-EP levels fell also, but this was not significant. In a third experiment, all animals underwent ADX, and half of them received daily subcutaneous injections of dexamethasone (20 µg). Nine days after ADX, the mean POMC mRNA level was 0.66 ± 0.04 pg/µg RNA in the saline-treated animals and increased to 0.98 ± 0.08 pg/µg RNA in the dexamethasone-treated animals (p < 0.005). A parallel increase in β-EP levels from 5.03 ± 0.41 to 6.01 ± 0.53 ng/mg protein was also noted, but this was not statistically significant. We conclude that POMC gene expression is significantly inhibited in the MBH at 1 and 2 weeks after ADX. This effect was reversed by glucocorticoid replacement with doses close to the physiological range. The parallel changes in POMC mRNA and peptide levels strongly suggest that, in contrast to the anterior pituitary, low doses of glucocorticoids stimulate the biosynthesis of POMC in the MBH of ADX rats.

Placental corticotropin-releasing hormone and the hypercortisolism of pregnancy

OBJECTIVE Our purpose was to clarify whether placental corticotropin-releasing hormone regulates pituitary-adrenal function in human pregnancy. STUDY DESIGN We examined the relationship between maternal plasma corticotropin-releasing hormone concentrations and levels of pituitary-adrenal hormones at 5-week intervals in 21 uncomplicated term pregnancies. RESULTS Maternal plasma corticotropin-releasing hormone concentrations rose significantly from 115 +/- 45 pg/ml at 11 to 15 weeks to 4346 +/- 754 pg/ml at 36 to 40 weeks (p < 0.001). Afternoon plasma corticotropin concentrations also rose significantly from 8.8 +/- 2.8 pg/ml to 18 +/- 2.6 pg/ml (p < 0.005). Urinary free cortisol concentrations rose from 54.8 +/- 7.3 micrograms per 24 hours to 111 +/- 8.7 micrograms per 24 hours (p < 0.005). Maternal dehydroepiandrosterone sulfate levels fell from 102 +/- 14 micrograms/dl to 63.8 +/- 7.1 micrograms/dl (p < 0.005). Maternal plasma corticotropin-releasing hormone was significantly correlated with afternoon plasma corticotropin concentrations (r = 0.6, p < 0.0001) and with urinary free cortisol concentrations (r = 0.04, p < 0.01). CONCLUSIONS Similar modest elevations of corticotropin and cortisol, as occur in pregnancy, have been reported in vitro and in vivo studies of long-term administration of corticotropin-releasing hormone. Our findings support the concept that placental corticotropin-releasing hormone modulates pituitary-adrenal function in pregnancy.

The effect of pre-eclampsia on human placental corticotrophin-releasing hormone content and processing

Prior studies have shown that levels of corticotrophin-releasing hormone (CRH) in the umbilical cord blood of infants born after pregnancies complicated by pre-eclampsia are significantly higher than fetal plasma CRH concentrations in uncomplicated pregnancies. In the present study we have measured CRH by radioimmunoassay in the placenta and fetal membranes from 13 pregnancies complicated by pre-eclampsia and compared them to 24 uncomplicated pregnancies. In addition we have investigated the effect of chronic intrauterine fetal stress on the processing of CRH in the placenta and fetal membranes. Placental CRH peptide content was significantly higher in the pregnancies complicated by pre-eclampsia, 12,900 +/- 4230 pg/g tissue, than in the uncomplicated pregnancies, 3130 +/- 430 pg/g of tissue (P < 0.01). Gel filtration of the homogenates of normal placenta revealed a major peak of CRH immunoactivity eluting in the same position as synthetic human CRH. A second smaller molecular weight peak of CRH-immunoactivity was also present and in both the amnion and the chorion, the CRH eluted in the position of the smaller molecular weight peak. In contrast, the bulk of the CRH immunoactivity in the placenta and fetal membranes obtained after pregnancies complicated by pre-eclampsia eluted in the position of intact synthetic human CRH. Thus, in pregnancy complicated by pre-eclampsia, both placental CRH release into fetal plasma and CRH peptide content is higher than in uncomplicated pregnancy.