Adi pose Tissue Inflammation in the Etiology of Obesity-Associated Chronic Disease

1. Adipose Tissue Inflammation in the Etiology of Obesity-AssociatedChronic Disease Mario Kratz, Ph.D. Associate Member, Fred Hutchinson Cancer Research Center Public Health Sciences, Cancer Prevention Program Research Assistant Professor, University of Washington Departments of Epidemiology & Medicine WHI Diabetes/Obesity Scientific Interest Group June 19, 2014

2. Overview Obesity Type 2Diabetes Low-grade chronic inflammation Diet

3. Overview Obesity Insulinresistance Type 2Diabetes Low-grade chronic inflammation Beta-celldysfunction ? Diet

4. Overview Obesity Insulinresistance Type 2Diabetes Low-grade chronic inflammation Beta-celldysfunction ? Diet

5. Overview IDEA-studyCROSSROADS Obesity Insulinresistance Type 2Diabetes Low-grade chronic inflammation Beta-celldysfunction ? Diet

6. Background “Old” Paradigm: the relationship between obesity, adipose tissue inflammation, and insulin resistance. Lumeng et al.; JCI 2007; 117: 175-84

7. Background “Old” Paradigm: the relationship between obesity, adipose tissue inflammation, and insulin resistance. Lumeng et al.; JCI 2007; 117: 175-84

8. Background “Old” Paradigm: the relationship between obesity, adipose tissue inflammation, and insulin resistance. - Adiponectin + Lumeng et al.; JCI 2007; 117: 175-84

9. Background “Old” Paradigm: the relationship between obesity, adipose tissue inflammation, and insulin resistance. CD11c+ - Adiponectin + Lumeng et al.; JCI 2007; 117: 175-84

10. Background Uysal et al.; Nature 1997; 389: 610-4Kanda et al.; JCI 2006; 116: 1494-1505Arkan et al.; Nat Med 2005; 11: 191-8 Orr et al.; Diabetes 2012; 61: 2718-27McGillicuddy et al.; Diabetes 2011; 60: 1688-98Weisberg et al.; JCI 2006; 116: 115-24

11. Background Uysal et al.; Nature 1997; 389: 610-4Kanda et al.; JCI 2006; 116: 1494-1505Arkan et al.; Nat Med 2005; 11: 191-8 Orr et al.; Diabetes 2012; 61: 2718-27McGillicuddy et al.; Diabetes 2011; 60: 1688-98Weisberg et al.; JCI 2006; 116: 115-24

12. Background TNF alpha IL-1 beta MCP-1 CCR2 TLR4 CD11c Uysal et al.; Nature 1997; 389: 610-4Kanda et al.; JCI 2006; 116: 1494-1505Arkan et al.; Nat Med 2005; 11: 191-8 Orr et al.; Diabetes 2012; 61: 2718-27McGillicuddy et al.; Diabetes 2011; 60: 1688-98Weisberg et al.; JCI 2006; 116: 115-24Patsouris et al.; Cell Metab 2008; 8: 301-9

13. Background - Summary • ‘Old’ paradigm: • Increased adiposity causes adipose tissue inflammation, which is the major cause for obesity-associated insulin resistance • The assumption was that an (unknown) pro-inflammatory trigger in adipose tissue causes macrophages to switch to a classically activated (“M1”) phenotype and causes the clonal expansion of Th1 T-cells and cytotoxic T-cells • “M1” macrophages, Th1 T-cells, and cytotoxic T-cells are the major producers of pro-inflammatory cytokines (TNFalpha, IL-1beta, IL-6, IFNgamma) • Adipose tissue inflammation = “bad”Reduction in inflammation = “good”

14. Objectives of this presentation • Assess the relationship between adiposity, adipose tissue inflammation, and insulin resistance in humans: • Cross-sectionally in a group of individuals varying widely in adiposity • Longitudinally as body weight and metabolic health change substantially after bariatric surgery

15. METHODS Snap-freeze whole tissue for gene expressionanalysis (qPCR) Adipose tissue Collagenase digestion Adipocytes Stromavascular cells (SVC) C Antibody Flow cytometry

16. METHODS

17. Obesity, Adipose Tissue Inflammation, and Insulin Resistance in Humans Individuals with chronic inflammatory conditions or those takinganti-inflammatory or anti-diabetic drugs were excluded.

18. Obesity & Adipose Tissue Inflammation in HumansCross-sectional associations Association between BMI and adipose tissue inflammation inhumans is rather weak. Is inflammation more closely associated with disease than BMI!?

19. CROSSROADS • Calorie Reduction Or Surgery: Seeking Remission for Obesity And DiabeteS (PIs: D. Cummings, D. Flum, UW) • Aims: • Establish the feasibility of novel methods to recruit an appropriate cohort for a RCT of gastric bypass surgery vs. best medical/lifestyle care to treat T2DM and obesity. • Conduct a pilot RCT of gastric bypass surgery vs. intensive lifestyle intervention of T2DM and obesity in patients with T2DM and a BMI of 30 to 40 kg/m2 • Explore the effects of RYGB vs. non-surgical weight loss on low-grade chronic adipose tissue inflammation clinicaltrials.gov registration number: NCT01295229

20. CROSSROADS – Study Design

21. CROSSROADS – Subjects

22. CROSSROADS – Results

23. CROSSROADS – Results

24. CROSSROADS – Results

25. CROSSROADS – Results

26. CROSSROADS – Conclusions • As expected, insulin sensitivity and glucose tolerance improved more after gastric bypass surgery than after similar weight loss induced by an intensive lifestyle intervention. • Improvements in insulin sensitivity and glucose tolerance after gastric bypass were not associated with a resolution of adipose tissue inflammation. • Some measures of inflammation (adipose tissue IL-1beta expression, numbers of neutrophil granulocytes) increased to a similar extend with weight loss in both groups. • Exactly the same result in a second longitudinal study of the relationship between adipose tissue inflammation and insulin resistance in individuals following bariatric surgery (follow-up at ~4 weeks and 6-12 months after surgery)

27. Conclusions • The lack of a reduction in adipose tissue inflammation associated with substantial improvements in glucose tolerance following bariatric surgery could be explained by: • A dissociation of the relationship between adipose tissue inflammation and insulin resistance • A shift towards non insulin-dependent modes of glucose uptake, i.e. increased glucose effectiveness. If this were the case, then the inflammation-insulin resistance link may not be affected by bariatric surgery, but may become less relevant for glucose homeostasis. Schwartz et al.; Nature 2013; 503: 59-66 Ryan et al.; Nature 2014; 509: 183-8

28. Why was adipose tissue inflammation not reduced with weight loss (even substantial weight loss ~12 months after bariatric surgery)?

29. Emerging paradigm • Immune cells in adipose tissue play major roles in maintaining tissue homeostasis • Role in angiogenesis • Role in adipose tissue expansion and remodeling • Role as a buffer for excess lipid • The activation and pro-inflammatory activity may be an indirect consequence of these physiological functions. • Macrophages in human adipose tissue are not classically activated “M1” cells. • Hypothesis: adipose tissue macrophages may acquire a pro-inflammatory phenotype due to exposure to free fatty acids. • Much less clear if adipose tissue inflammation = bad. While low-grade chronic inflammation likely is a major cause of insulin resistance, lack of an appropriate immune response to pro-inflammatory stimuli may have more severe health consequences. Xu et al.; Cell Metab. 2013; 18: 816-30 Wernstedt-Asterholm et al.; Cell Metab. 2014; 20: 1-16

30. Acknowledgements FHCRC: • Derek Hagman, Ph.D., M.P.H. • Ilona Larson, Ph.D. • Gail Cromer, M.S. • Jessica Kuzma, M.S. • Karen Makar, Ph.D. • Xiaoling Song, Ph.D. • Staff of the Prevention Center • Staff of the Flow Cytometry Shared Resource Group Health Research Institute: • David Arterburn, M.D., M.P.H. University of Chicago: • Lev Becker, Ph.D. University of Washington: • David Cummings, M.D. • David Flum, M.D., M.P.H. • Karen Foster-Schubert, M.D. • Brian van Yserloo, B.S. • Staff of the Clinical Research Center Puget Sound Surgical Center, Edmonds, WA: • Peter Billing, M.D. • Rob Landerholm, M.D. • Matt Crouthamel, M.D. ADA Clinical/Translational Research Award 7-09-CT-36 (PI: Kratz)NCI R21CA143248 (PI: Kratz)NIDDK R01 DK089528 (PI: Cummings / Flum)